low-volume work options

[rkaz]

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Hi all. I'm about to start my final year of child fellowship, and will be looking for job opportunities soon. I really love my work, and enjoy working with kids and families. I've been told that I do a great job by my attendings and my patients. My issue is that I'm super slow in writing my notes, and it just takes too long for me. (I have my own issues with ADHD, and tend to be a perfectionist. My notes are way more comprehensive than the attending notes.) It has been an issue throughout residency and fellowship, and while my efficiency has improved, I still spend way more time than I should be. Efficiency is the only issue for me, as I've been told my work and medical decision making are solid (and I am already board-certified in psychiatry). In the past, I could work from 8am to 11pm to get all my work done, as I have been willing to do whatever it took to get through. However being a woman in my mid-30s, hoping to have a marriage and family and an appropriate work/life balance in future, I don't see this working out long term.

Money isn't that important to me, as my time is what I value most. I would be perfectly fine making $140k+, if I could get a job with a great lifestyle (limited call, full-time benefits, time for conferences, etc). It seems like it takes way longer for me to see children than it did to see adults (as there is so much calling parents for collateral, medication approvals, calling case managers/CPS, etc). And writing notes takes up several hours of my day. Would it even be possible to ask my future employers to cap me at 6 patients/day (with up to 2 of those 6 being new patients)? In this case, I am referring to inpatient work, although I'd be willing to consider a similar volume for outpatient (if I could get 90 min new patient visits, and 45min+ follow-up visits), although I don't know where to find such positions. In order to do this, would I need to specifically look for part time work, or would there be "full time" options that have low-volume/low call (such as college student mental health)? I may be even open to jobs that have a comparatively larger admin time (vs all clinical). I'd appreciate any guidance. Thank you!

 

[TexasPhysician]

You a fan of Texas?

A cash pay practice like mine would probably be ideal as most requests can be accommodated at the expense of salary.

 

[clausewitz2]

Hi all. I'm about to start my final year of child fellowship, and will be looking for job opportunities soon. I really love my work, and enjoy working with kids and families. I've been told that I do a great job by my attendings and my patients. My issue is that I'm super slow in writing my notes, and it just takes too long for me. (I have my own issues with ADHD, and tend to be a perfectionist. My notes are way more comprehensive than the attending notes.) It has been an issue throughout residency and fellowship, and while my efficiency has improved, I still spend way more time than I should be. Efficiency is the only issue for me, as I've been told my work and medical decision making are solid (and I am already board-certified in psychiatry). In the past, I could work from 8am to 11pm to get all my work done, as I have been willing to do whatever it took to get through. However being a woman in my mid-30s, hoping to have a marriage and family and an appropriate work/life balance in future, I don't see this working out long term.

Money isn't that important to me, as my time is what I value most. I would be perfectly fine making $140k+, if I could get a job with a great lifestyle (limited call, full-time benefits, time for conferences, etc). It seems like it takes way longer for me to see children than it did to see adults (as there is so much calling parents for collateral, medication approvals, calling case managers/CPS, etc). And writing notes takes up several hours of my day. Would it even be possible to ask my future employers to cap me at 6 patients/day (with up to 2 of those 6 being new patients)? In this case, I am referring to inpatient work, although I'd be willing to consider a similar volume for outpatient (if I could get 90 min new patient visits, and 45min+ follow-up visits), although I don't know where to find such positions. In order to do this, would I need to specifically look for part time work, or would there be "full time" options that have low-volume/low call (such as college student mental health)? I may be even open to jobs that have a comparatively larger admin time (vs all clinical). I'd appreciate any guidance. Thank you!

One of my favorite residency supervisors sort of does this. He is the psychiatrist for several of our IOP groups and puts in full time hours but only sees patients equivalent to 0.8 FTE (and is paid accordingly). Might want to look for intensive outpatient programs that are sort of designed for someone to be able to see a bunch of folks in a morning but that will let you stretch it out over a few days per week.

 

[rkaz]

You a fan of Texas?

A cash pay practice like mine would probably be ideal as most requests can be accommodated at the expense of salary.

Yes, I do like Texas (esp the more progressive cities like Austin)! I'm currently considering the west/southwest states (California, Oregon, Arizona, New Mexico, Texas).

Thank you! The cash practice idea seems like one reasonable option for me to consider.

 

[rkaz]

One of my favorite residency supervisors sort of does this. He is the psychiatrist for several of our IOP groups and puts in full time hours but only sees patients equivalent to 0.8 FTE (and is paid accordingly). Might want to look for intensive outpatient programs that are sort of designed for someone to be able to see a bunch of folks in a morning but that will let you stretch it out over a few days per week.

Thank you. The IOP idea seems like a great one as well, as it would allow me to know what I have to see in the morning and thus I can plan out my day better. At the same time, I'm hoping that the call burden might be less than inpatient, though I'd have to talk to someone working in IOP to know more about this.

As part of loan forgiveness options (like PSLF), I think I will have to find something that is "full time". So this throws another dimension of complexity into the mix. I'd love the option of being 0.7-0.8FTE like your residency supervisor (as knowing me, I'd still be there full time hours anyway). So hopefully this would still be considered "full time". But the extra time (outside of direct clinical work and note writing) would also allow me the chance to do other things I enjoy, such as teaching students, looking up interesting journal articles on treatment approaches for more complex patients, preparing lectures, doing admin activities, etc.

 

[Monocles]

Come to Massachusetts! We have a level of care called partial and it's basically in between IOP and inpatient. Essentially you get paid full time but work 8-3 or whenever the program is over.

 

[Sushirolls]

Wanting to do PSLF and accomodations for over documentation is going to be hard match up.

If you drop the PSLF, go cash outpatient you will stand a better chance of not burning out and enjoying your daily practice and time you put in with patients.

Go the PSLF, you'll be looking at long hours and dissatisfaction, and will ultimately cut into your desires for better work/life/family balance. It is possible for some places to consider paying you less to let you document more, but don't count on it. More likely to happen they will suggest giving you a scribe, reduce your pay some (likely less than what you would propose to do documentation yourself) and still expect you to see the same volume.

I highly suggest you find a part time gig, forget the PSLF, and open your own private practice on the side. Then sooner you enter into the ideal family balance job the better it will be. Trying to react to finding a family balance set up (personalized to you) after you have 1-3 toddlers running around will just be chaos. Think you are inefficient and slow now with no kids/family? Wait until you have a spouse who comes with their own strengths/weaknesses to the family unit, and dealing with childcare, potting training, pediatric appointments, finding quality time with kids, sick kids, etc, etc, etc, By the time you get them to bed you will be tired and exhausted, and the notion of notes late at night is "hell no." Personally I burned the candle at both ends in residency, with moonlighting that put me into 80-100hrs per week, plus socializing with residents. The difference from then and now, is with kids, you don't get a day to crash and catch up on sleep. LOL, there is no sleep catch up with kids.

 

[TexasPhysician]

As part of loan forgiveness options (like PSLF), I think I will have to find something that is "full time". So this throws another dimension of complexity into the mix. I'd love the option of being 0.7-0.8FTE like your residency supervisor (as knowing me, I'd still be there full time hours anyway). So hopefully this would still be considered "full time". But the extra time (outside of direct clinical work and note writing) would also allow me the chance to do other things I enjoy, such as teaching students, looking up interesting journal articles on treatment approaches for more complex patients, preparing lectures, doing admin activities, etc.

If you need PSLF, the better options for lifestyle are probably academia. Most academic gigs will be 8-5 with some call and weekends.

 

[psyguru]

I used to work at a state supported residential facility for severe IDD and Autism and was seeing 6 patients a week and attending 2 hours of meetings a day. The notes were long but you could do one a day so it is manageable (I did 6 in one or two days). However 95% of psychiatrists dont have an affinity for this type of work. Half the patients are non-verbal.

Also I was seeing death row and ad seg patients and averaging about 5 patients a day. The less secure units may have had more patients per day.

Another options is medical director.

If you like writing long notes you should get paid for it...and paid well....consider doing forensic psychiatry and expert work. I do up to 20 page reports and have interviewed murder suspects up to 8 hours. Attorneys pay you per the hour at triple the clinical rate. You could work one day a week clinically and invoice 150 hours of forensic work a year (about 12 hours a month....generally 1 to 2 independent medical exams a month and make about 140k). It is possible to do lower lying expert witness work/ IME without forensics training. If you dont like to testify just remember it is rare and you could pick low lying disability cases or utilization review work that will almost never involve testimony. However some of these not pay as well or even hourly.

I probably testify in about less than 5% of the cases and for me, I prefer an 8 hour depo over with 4 days off vs having to see patients for 40 hours.


Once you are an attending, confidence will grow and you may find yourself able to write shorter notes. Get a good template and use dictation software. If you can resolve the extensive documentation soon rather then than 30 years it maybe easier.

 

[psyguru]

There is an opening in Brenham tx for the IDD facility. You could live in west Katy...a suburb of Houston.

 

[Monocles]

The other question to address is -- would you be willing to figure out ways to improve your efficiency?

I'm at the opposite end of the spectrum in that I'm always done with the bulk of my work in 70% of the allotted time. My personal belief is that the more you document, the less gets read so my notes are always the critical tl;dr of a patient's care. Have you thought about what would happen if you wrote less novels?

 

[Merovinge]

I agree with Monocoles. I am a CAP attending, and super long notes are a bit of a pet peeve of mine that seems to propagate in our specialty even more than general psychiatry which is notoriously ridiculed by other specialties for our lack of parsimony. You really want to look at meeting every billing requirement and then having a good assessment/plan. Most of the rest is going to be fluff that could be taken by someone else (be it psychologist, social worker, nurse).

For one example, we do have some areas that need extra questions (e.g. developmental history) but you don't need to write a page on every milestone, it becomes pretty easy to figure out with a few questions if speech/motor/ADLs were delayed and if special services were received.

One of your best value adds as a physician is being able to distill down an incredible amount of information into a short paragraph assessment that allows both yourself and others treating this patient to understand the core issues. If you write a page long assessment, no one will read it and it will be less helpful to the patient.

Having said all that, it you want to see less patients a day and will take a low salary, there should definitely be options in clinical educator tracks at academic positions, at IOP/PHP/IP that pay you per patient, or even private outpatient as others have mentioned. I would make sure to do some employed work to start, jumping into a cash practice right out of training is tricky for all but the most business minded.

 

[Stagg737]

Idk how realistic it is where you are, but one of my residency rotations so far was at a long-term care facility (geri psych) where we would stop in and see patients every day but only wrote a note once per week on them. It might be harder to do in CAP, but I know of a residential treatment program near where I attended med school (I rotated at the affiliated inpt unit) that has a somewhat similar set-up in the sense that the docs weren't writing notes on everyone every day. Something like that could also potentially qualify for PSLF or another form of forgiveness, as the one I mentioned treated a significant number of foster kids and was heavily associated with the state.

Edit: Missed psyguru's post, but sounds like a similar set-up to what he suggested but wasn't limited to ASD or IDD kids.

 

[rkaz]

Thank you all so much for your excellent thoughts and suggestions. I greatly appreciate it. I was busy last week... writing long notes, probably, 😕 and didn't have the chance to check this, and then spent the weekend trying to recover by doing nothing psychiatry related. Will reply with more specifics soon.