meow1985

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So I'm just curious.

This forum seems to have a number of people in private practice (I'm talking small, psychiatry only groups), and seems to advocate that this form of practice as desirable for a number of reasons.

My concern about that would be, though, how do you keep abreast of what's going on with your patients medically? How do you get requisite labs and workup?

Whenever I have patients who need EKG's, blood draws, urine drug screens, etc, more than half the time it's like herding cats getting people to do those things. I'm part of a university system, but our clinic doesn't have a lab in the building, so we send people to primary care clinic down the street. Still, the half-mile they need to drive seems to be an insurmountable barrier to many people. One psychiatrist in our department has started doing his own UDS's, but those are just dipstick ones: not as reliable as ones done in a lab, and we're not equipped to make sure the sample wasn't tampered with.

Coordinating with PCP's (i.e. when someone's stable and can go back to primary care, or needs a medical issue taken care of) is ok if the PCP is in our system. But if they're not, it eats up my and my RN staff's time with paperwork and phone calls. And a lot of the time, patients aren't reliable reporters of their own health status so not being able to review that info in the chart makes me uncomfortable.

Finally, I find myself needing to order a lot of sleep studies. I have no idea what I'd do if there wasn't a sleep clinic in our system.

How does everyone else in solo or small group private practice deal with this?
 

Ironspy

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Private patients are higher functioning in general. I tell them to get labs and get results faxed back to me. Ditto with EKGs and sleep studies. I have a micro practice but so far this has been a non issue. I occasionally need to remind them. Medically fragile patients need a higher level of care as I don’t think I could provide adequate monitoring in my current setting. I do Li, drug levels, CBC, bmp, tsh, lipids with regularity. I don’t currently have anyone on controlled substances but if I did I’d want utox which can be done at the labs my patients are already using

Lots of sleep clinics and I tell patients to pick one and have the results faxed
 
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Sushirolls

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You do the same as you normally do...

I practiced in a big box shop with a range of lower and higher functioning patients. You write the orders, tell the patients, explain the merits, and explain where they can get the labs drawn. Make it easier by printing out the locations and times and how to get the labs, and encourage the "early bird gets the worm" so they don't get stuck in que for long waits.

In private practice I don't have to do deal with the scat of referring only to your own lab. Technically even in a Big Box shop you don't have to refer in house, but if mid management starts to notice your referral patterns they are going to grumble and you need to be willing to quit your job and walk away because some one is going to keep giving you a hard time. Or like one colleague I know be threatened with things like "that's a breach of contract" verbiage for referring outside the system - despite the fact no system (except maybe an HMO?) can constrain your referrals. I instruct patients on where their lab options are, Quest, LabCorp, local hospital Alpha Beta, local hospital Theta Omega, or with their independent primary care who has labs internally. Let the patient decide where they want to go. Just print the orders on a sheet and hand it to them. I go the extra step of typing out PLEASE FAX RESULTS so as to remind the lab to, fax the results.

Even my higher functioning patients need reminders. You just remind them every visit. Re-explain and document the why you are ordering the labs and possible consequences of undiagnosed conditions without the labs. Keep re-printing the order sheets if necessary. Untreated thyroid disorders? Worsening liver failure? etc.

Those dipstick tests your Psychiatrist is doing is just as reliable as the ones in a lab. They are the same CLIA waived tests. I encourage you to do an MRO course for CME some time, it'll make more sense. The only issue you point out is the tampering which can be mitigated by adulterant type tests. Specific gravity, creatine, pH, etc. The only next step beyond that is observed urine tests, which really is unnecessary unless you are functioning in a forensic, court, or MRO fashion.

PCP coordination is the same whether in a Big Box shop or private practice. Send a fax. Pick up the phone. Call their office yourself. Get the personal cell phones of the PCPs. I.e. Send a text message. "faxing over a progress note I hope you read today on a mutual patient, call me if any questions later. -Sushirolls. My experience even in Big Box shops, PCPs typically wouldn't even read the messages or forwarded notes. At best their MA would, in part because they were too darn busy. Currently with one Big Box shop I have the contact details of their Primary Care social worker, and I just call her fax things to her and vice versa. You just need one good line of communication with one person. Overall the primary care in your area is a fixed quantity. There aren't that many different offices, especially as people drink the koolaid and fly the corporate medical flag so you'll quickly learn your communication channels. The other thing is some Docs (I don't) have their patients bring in all the meds in order to review the bottles to have an accurate med list. I don't, but partially because Luminello as an EMR does a decent job of tapping into the Pharmacy databases and showing the most recent Prescriptions, so you can stay on top of most recent dose changes. Or worst case scenario, you tell the patient 'I'm not making any changes today until you get me information XYZ" whether it is them clarifying what their dose is for concerning medicine Zeta Benzo or consultant progress note from Heme, Hepatology, Cardiology, etc.

With time you may be more comfortable with not having all that information at your finger tips. Part of why I am more comfortable is by avoiding the more concerning medicines. Benzos? Z drugs? And if I do trend in to our higher side effect profile meds in conjunction with a higher risk patient, I expend more effort to get those extra clinical data before making choices. If I don't have it, we wait, and patient has to wait longer for results. Is what it is.

I'm glad to hear you make a lot of referral to sleep medicine. I range from 25-75% of may consults depending on the week. I practiced at a Big Box shop where the other psych rarely made referrals, and most all my patients were referred. I've had now maybe 5 patients in past 5 years that I've referred who didn't have OSA. So important to get OSA treated. Sleep medicine is pretty well saturated. Do some google searches, and you'll find them. People will drive to those consultants. The bigger question isn't so much access to Sleep Medicine, but will your patients get a physician or mid-level? Nothing more frustrating then sending a parasomnia +/- RLS +/- RBD +/- OSA consult and you get a simple ARNP note back saying only rule out OSA and they didn't even chart or fight to get the in lab study to start nor discuss ordering ferritin iron labs, etc..

Long story short, private/small/solo practice is still better then Big Box shop and not being attached to the Big Box shop Epic or Cerner EMR really isn't that bad. I don't miss it.
 
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Sushirolls

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Oh, and past chart notes? Mostly a waste of time. Rarely do I see things of clinical pertinence at the outpatient level (inpatient I have for sure). Many notes are sparse, limited HPI to support Assessment, or its a check box heavy EMR with yes no auto-populated questions that are just painful to process. Worse yet are the hand written notes which just aren't legible. Or what usually happens is the docs retired or moved, so no where to fax and acquire records from. Or they clinic is hand written notes and purged them after the permitted 7? years. Or they just simply don't ever fax them despite multiple attempts.

For past psychotropic trials having sheets with all know meds on it, and simply check boxing them is probably the best means to get that covered. You will rarely see a past records from other clinics with a good, concise summary. Most patients can usually recall that minimal yes/no I took it, which is a good enough starting point to branch from in the office to get the good details of those trials.
 
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meow1985

meow1985

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Sep 12, 2017
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I practiced in a big box shop with a range of lower and higher functioning patients. You write the orders, tell the patients, explain the merits, and explain where they can get the labs drawn. Make it easier by printing out the locations and times and how to get the labs, and encourage the "early bird gets the worm" so they don't get stuck in que for long waits.
All good info. Interestingly, though, my more medically ill and complex patients are slightly better at getting labs, maybe because labs and other tests are already a familiar part of their life. I have more trouble with the high-functioning ADHD-ers who work full-time high-responsibility jobs but can't remember to run one errand. I end up having to hold their meds hostage, and then get yelled at for "being treated like a drug addict."

Maybe I need to do the dipstick thing too, except in our system it's not "official" somehow if you do that. Pffft... Likely the system just trying to make money by using the lab.
 

Sushirolls

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The lab bit gets tricky. You need a CLIA lab waiver certificate thru the state. Typically a 1-2 page document to fill out. But some one needs to be listed as the medical director. And may need some policies for how/when you will run the positive test reagents. What I suspect is the hospital health system lab, is pointing out you don't currently have the CLIA lab waiver (easy fix). But what they are more worried about is that this will be a few dollars not run thru their department but instead now going into the budget/pay for your psych department instead. Labs don't like that, even if it is small dollar values.

Been there, done that, with that exact bureaucratic fight before. Have fun.
 

Jules A

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All good info. Interestingly, though, my more medically ill and complex patients are slightly better at getting labs, maybe because labs and other tests are already a familiar part of their life. I have more trouble with the high-functioning ADHD-ers who work full-time high-responsibility jobs but can't remember to run one errand. I end up having to hold their meds hostage, and then get yelled at for "being treated like a drug addict."

Maybe I need to do the dipstick thing too, except in our system it's not "official" somehow if you do that. Pffft... Likely the system just trying to make money by using the lab.
If you have a large number of "high-functioning ADHD-ers" who are getting nasty when you request diagnostics consider taking a careful look at that entire picture. And just curious why so many sleep studies?

OTOH chasing down lab results is a total circus. I generally have more who have gotten labs done and for whatever reason the lab can't seem to fax me the results. I stopped adding PCP etc. on lab slips thinking perhaps they were sending it to them instead with no change. I have started asking patients to call the office after they get labs so we can track them down if not sent.
 
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downwithDTB

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And just curious why so many sleep studies?
Prevalence of OSA is higher than most psych conditions. Where do you go (OR where does your PCNP send you) when you're having trouble concentrating or you have low energy and feel off, especially if you have early morning awakenings?

You can get a pretty good PHQ-9 off of OSA. At least that's why I end up ordering a bunch in outpatient adult settings. Often the story is weak for MDD/, great for OSA, and instead of asking if he snores, I say "does you wife ever call you bear?" And get a "doc, how'd ya know? You psychiatists, really are mind readers...".
 
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meow1985

meow1985

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Sep 12, 2017
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Prevalence of OSA is higher than most psych conditions. Where do you go (OR where does your PCNP send you) when you're having trouble concentrating or you have low energy and feel off, especially if you have early morning awakenings?

You can get a pretty good PHQ-9 off of OSA. At least that's why I end up ordering a bunch in outpatient adult settings. Often the story is weak for MDD/, great for OSA, and instead of asking if he snores, I say "does you wife ever call you bear?" And get a "doc, how'd ya know? You psychiatists, really are mind readers...".
Also if there's untreated OSA and you're trying to treat someone with stimulants for ADHD, that's dangerous from a CV standpoint.
 
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meow1985

meow1985

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If you have a large number of "high-functioning ADHD-ers" who are getting nasty when you request diagnostics consider taking a careful look at that entire picture. And just curious why so many sleep studies?
Part of being at a large group practice and in a resident clinic is that I inherit a lot of patients from other people. Could they not actually have ADHD? Yes. Could it be that whoever started treatment in the first place didn't properly set limits? Also yes. Could I myself have been too naive and green when I started the stimulant and given them an inch only to have them take a mile? Yes. Either way, it's hard to undo other people's - and your own - earlier practices that are not optimal. Once someone gets a taste of a stimulant, they often find nothing else works quite as well, and even people without ADHD can benefit from stimulants just as they do from coffee. And then try and tell them that they don't have ADHD and they don't actually need their adderall? You're in for a world of pain as a provider, especially when you can't fire people. :)
 

clausewitz2

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Part of being at a large group practice and in a resident clinic is that I inherit a lot of patients from other people. Could they not actually have ADHD? Yes. Could it be that whoever started treatment in the first place didn't properly set limits? Also yes. Could I myself have been too naive and green when I started the stimulant and given them an inch only to have them take a mile? Yes. Either way, it's hard to undo other people's - and your own - earlier practices that are not optimal. Once someone gets a taste of a stimulant, they often find nothing else works quite as well, and even people without ADHD can benefit from stimulants just as they do from coffee. And then try and tell them that they don't have ADHD and they don't actually need their adderall? You're in for a world of pain as a provider, especially when you can't fire people. :)
Sure, you can't fire people in a resident clinic but outside of the sketchiest places the patients are not holding guns to your head and forcing you to write the script. It is okay to say no and it is okay for them to be mad about it. These are not benzos, nothing medically dangerous will happen if you stop them abruptly (unless they are for narcolepsy of course). If you are physically afraid if what will happen if you piss them off that's a whole different conversation you need to be having with the clinic director.
 
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Jules A

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Part of being at a large group practice and in a resident clinic is that I inherit a lot of patients from other people. Could they not actually have ADHD? Yes. Could it be that whoever started treatment in the first place didn't properly set limits? Also yes. Could I myself have been too naive and green when I started the stimulant and given them an inch only to have them take a mile? Yes. Either way, it's hard to undo other people's - and your own - earlier practices that are not optimal. Once someone gets a taste of a stimulant, they often find nothing else works quite as well, and even people without ADHD can benefit from stimulants just as they do from coffee. And then try and tell them that they don't have ADHD and they don't actually need their adderall? You're in for a world of pain as a provider, especially when you can't fire people. :)
I have inherited patients on what I feel are inappropriate medications several times in the past and it is an adjustment period for all involved. Once you take them the handiwork is yours. If you feel the regimen isn't appropriate it is your duty to address it and attempt to educate them, although like you pointed out it will likely be uncomfortable. What I have found is when I stopped prescribing the medications they were seeking most fired me and many of those who stayed improved despite not having whatever magic pill they initially felt they couldn't live without.
 
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meow1985

meow1985

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I have inherited patients on what I feel are inappropriate medications several times in the past and it is an adjustment period for all involved. Once you take them the handiwork is yours. If you feel the regimen isn't appropriate it is your duty to address it and attempt to educate them, although like you pointed out it will likely be uncomfortable. What I have found is when I stopped prescribing the medications they were seeking most fired me and many of those who stayed improved despite not having whatever magic pill they initially felt they couldn't live without.
If the meds are obviously inappropriate I definitely have a conversation about that and most of the time people are willing to work with me on a new plan.

The issue is the grayer area where ADHD treatment is arguably more in the realm of enhancement. Like, someone is now great at their job when before they were mediocre (though nowhere close to being fired). These people are also usually very minimally motivated to pursue non-pharm interventions, at least once the stimulants are already on board. When you discuss the risks, they just shrug and say "that's fine with me," because they're usually on the younger side and words like "stroke" mean very little to them. But I'm not exactly justified in telling them a hard and fast no.
 

clausewitz2

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If the meds are obviously inappropriate I definitely have a conversation about that and most of the time people are willing to work with me on a new plan.

The issue is the grayer area where ADHD treatment is arguably more in the realm of enhancement. Like, someone is now great at their job when before they were mediocre (though nowhere close to being fired). These people are also usually very minimally motivated to pursue non-pharm interventions, at least once the stimulants are already on board. When you discuss the risks, they just shrug and say "that's fine with me," because they're usually on the younger side and words like "stroke" mean very little to them. But I'm not exactly justified in telling them a hard and fast no.
There are reasons to object to using stimulants for cognitive enhancement that I can respect but unless these healthy adults are in afib or have massive hypertension they are not going to stroke out from a stimulant at clinically relevant doses. Cardiologists never really care about stimulants absent a proven significant arrythmia. This is similar to the issue with seizure risk and stimulants in kids with epilepsy, where we freak out and pediatric neurologists issue guidelines saying "nah, it's fine, not an issue."

Again, the calculus changes if the Addys are going straight up their nose but if you think that is happening you are having a different conversation....
 
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meow1985

meow1985

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There are reasons to object to using stimulants for cognitive enhancement that I can respect but unless these healthy adults are in afib or have massive hypertension they are not going to stroke out from a stimulant at clinically relevant doses. Cardiologists never really care about stimulants absent a proven significant arrythmia. This is similar to the issue with seizure risk and stimulants in kids with epilepsy, where we freak out and pediatric neurologists issue guidelines saying "nah, it's fine, not an issue."

Again, the calculus changes if the Addys are going straight up their nose but if you think that is happening you are having a different conversation....
But those healthy adults will age and will develop some of those very issues (like HTN), and the stimulant they're taking won't make it any easier to treat. But then they be all like, "can't I just take anti-HTN meds, what's the problem?"

Also, if they're going to use adderall for enhancement, they should be able to play by my rules, which is like pulling teeth. Back to my original point.
 

clausewitz2

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But those healthy adults will age and will develop some of those very issues (like HTN), and the stimulant they're taking won't make it any easier to treat. But then they be all like, "can't I just take anti-HTN meds, what's the problem?"

Also, if they're going to use adderall for enhancement, they should be able to play by my rules, which is like pulling teeth. Back to my original point.
At the end of the day you have the power in this situation, no matter how powerless they may make you feel. You make clear the conditions under which you will continue to prescribe, give them whatever grace period you think is reasonable, then you stop prescribing if the conditions you laid out are not met. The circumstances under which someone is going to successfully sue you for not giving them a highly controlled substance you are concerned they are not using correctly and has no meaningful withdrawal are almost inconceivable.
 
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