Number of patients (inpatient only) per day

[nexus73]

This topic has been discussed some on the board and I've read thru the previous threads, but never seen any "official" answers. I was wondering if there are published recommendations for max number of inpatients per day from APA or another professional society. I haven't been able to find anything with google search. The issue I'm facing is our inpatient unit is understaffed and hospital admin is pushing for us fewer psychiatrists/NPs to see more patients. The only data I've found for psychiatry are informal forum posts where doctors list the numbers they see per day...which range widely from 8 to 20+ per day...so the numbers there are pretty useless to take to admin (they would just tell us to see 20 per day).

I talked with an IM hospitalist colleague and their professional societies have clear recommendations on number of patients per day. He said hospital admin was pushing them hard to increase their patient loads, but once they were shown the recommended limits, admin totally backed off. I'm looking for something similar for psych for my own knowledge, and to take to admin to work out an agreed patient load. It would be nice to see a distribution with median and standard deviation so I could push for increased RVU pay for higher than median patient load.

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[MedMan80]

I think it is harder to prove such numbers in psychiatry, as it probably is easier to take care of 20 psych inpatients (especially if you have a IM doc taking care of medical stuff) vs 20 medically complicated patients, the real burnout in psych would happen with disposition pressures etc..

 

[wolfvgang22]

For me, I would want no more than 12 inpatients, particularly if I don't have a scribe or midlevel or senior residents residents helping me. Come to think of it, that is my favorite outpatient number, too. Sure, I could make more money seeing more, but I'm in it for the long haul.

 

[OldPsychDoc]

To answer your question, no. No such guidelines exist.

 

[nexus73]

I think it is harder to prove such numbers in psychiatry, as it probably is easier to take care of 20 psych inpatients (especially if you have a IM doc taking care of medical stuff) vs 20 medically complicated patients, the real burnout in psych would happen with disposition pressures etc..

This is an interesting perspective to me. I always felt it was easier to see more internal medicine patients than psych patients. With medical issues you have the vitals, labs, key physical exam findings, etc...and daily subjective history from the patient is less necessary. Whereas in psych you have to talk to the patient to find out how they're doing which I think takes more time than looking up cbc results and listening to their lungs, for example.

I've definitely seen "efficient" psychiatrists see 20 patients per day, where each visit is basically checking in for mood/energy/appetite/SI/HI, then they're on to the next patient. But I think this is not great care, and if you do this you end up discharging patients without really knowing what's going on with them.

 

[Stagg737]

This is an interesting perspective to me. I always felt it was easier to see more internal medicine patients than psych patients. With medical issues you have the vitals, labs, key physical exam findings, etc...and daily subjective history from the patient is less necessary. Whereas in psych you have to talk to the patient to find out how they're doing which I think takes more time than looking up cbc results and listening to their lungs, for example.

I've definitely seen "efficient" psychiatrists see 20 patients per day, where each visit is basically checking in for mood/energy/appetite/SI/HI, then they're on to the next patient. But I think this is not great care, and if you do this you end up discharging patients without really knowing what's going on with them.

Agree with the bolded. After the first week I felt like it was pretty easy to carry 6-8 IM patients, whereas 6-8 psych patients still feels like a moderately heavy load depending on how severe they are (had 4 people in active mania at once and it was exhausting). Agree that the testing is easier too. If an issue comes up with a patient on the medical floor a lot of the time you can just order imaging or labs without having to spend more than 2 minutes with the pt. If a pt has a complaint on the psych unit, you're typically spending at least 5 minutes with them. Sometimes 15-20 if it's something more serious.

I had an attending who would see up to 25 patients per day and was often done by around 1 or 2. He also didn't do any charting until after he'd seen everyone though and he always had 3 med students and a nurse working with him for collateral, so it's definitely doable if you're efficient. He also made it very clear to patients that while he was happy to refer them for counseling or have them see the therapists on site, he did not practice psychotherapy (though looking back he did do some occasionally). We can ask as to whether that's truly providing the best care, but with proper ancillary staff and being able to refer to appropriate counseling/therapy services, it seemed to work really well for him and his patients (who were some of the most stable patients on f/up I've ever seen).

 

[Sushirolls]

8-12 is considered full time. Anything more than that you are working too hard, and in my opinion quality can start to diminish. Admissions take time, and discharges take time. Plus family meetings / education. Families need some degree of education on 'what is schizophrenia' and borderline patients deserve to get the diagnosis, educated on it, and told about DBT - not just charted and never told anything. Every patient should have an order from day one requesting outside records, and if/when they arrive those should be reviewed. It also takes time to do civil commitments and the court testimony for that (variability per unit and state). Then there are the peer reviews, and insurance appeals.

Are there doctors who see 15, 16, 20, 20+ per day? Yes there are. I encourage you to review those notes. My experiences have observed their notes to have less details, which makes it harder for the UR folks to make sure days get authorized and paid for. Also should any insurance company decide to start a rack[sp?] audit, there is a good chance they will get hammered on review. Depending on the place's contract/policy the institution or the doctor will foot bill for recuperation. Let's not forget the rising list of bureaucracy that JCAHO has bestowed upon charting that must be done. Forget one little detail, someone so where will eventually find you to say hey, this needs to be charted.

Sure there are clinicians who have no problem seeing higher numbers of patients with minimalist notes. I for one am not one. More and more data comes out reflecting that even after discharge from a hospital patients are still at elevated suicide risk, and if a patient were to unfortunately complete it, and folks request your records after the fact; would you be confident in what you charted?

I walked away from an inpatient gig that was pushing the higher numbers. Jumping into private practice now.

 

[MedMan80]

8-12 is considered full time. Anything more than that you are working too hard, and in my opinion quality can start to diminish. Admissions take time, and discharges take time. Plus family meetings / education. Families need some degree of education on 'what is schizophrenia' and borderline patients deserve to get the diagnosis, educated on it, and told about DBT - not just charted and never told anything. Every patient should have an order from day one requesting outside records, and if/when they arrive those should be reviewed. It also takes time to do civil commitments and the court testimony for that (variability per unit and state). Then there are the peer reviews, and insurance appeals.

Are there doctors who see 15, 16, 20, 20+ per day? Yes there are. I encourage you to review those notes. My experiences have observed their notes to have less details, which makes it harder for the UR folks to make sure days get authorized and paid for. Also should any insurance company decide to start a rack[sp?] audit, there is a good chance they will get hammered on review. Depending on the place's contract/policy the institution or the doctor will foot bill for recuperation. Let's not forget the rising list of bureaucracy that JCAHO has bestowed upon charting that must be done. Forget one little detail, someone so where will eventually find you to say hey, this needs to be charted.

Sure there are clinicians who have no problem seeing higher numbers of patients with minimalist notes. I for one am not one. More and more data comes out reflecting that even after discharge from a hospital patients are still at elevated suicide risk, and if a patient were to unfortunately complete it, and folks request your records after the fact; would you be confident in what you charted?

I walked away from an inpatient gig that was pushing the higher numbers. Jumping into private practice now.

I had a place offering me to see 22+ kids, with help of NP and a scribe and I walked away. No way you can see that many kids and do a competent job, in between all the family work and the higher acuity of kids and you're asking for problems. Don't sell yourself short.

 

[whopper]

My current limit of patients is mostly because I want to spend more time with my kids and wife.

I know I reached a personal limit sometime around 65-70 hrs a week. At that point I'd get calls and the patients wouldn't be quite as familiar, my handle on some of the patients weren't as good as I'd like, and my tolerance for BS that would go on would be a hell of a lot less but to the point where I'd spend over an hour being very angry.

Mind you the time is relative. E.g. if I worked 50 hrs a week at a dysfunctional place my tolerance of working there would likely be much less.

 

[Jules A]

I've seen between 8-15 when fully staffed. In my opinion the sweet spot is some where around 10-12 although if med floor consults are included it drops to 8 for me.

 

[NickNaylor]

All of our units, when at capacity, result in an attending having no more than 7-8 inpatients to see per day. This assumes that all of the other attendings are there as well.

One of my psychotherapy supervisors did inpatient work in addition to having his own practice, and he said that it wasn't uncommon to see 15-20 patients per day in a strict production-based compensation model at private hospitals.

 

[DisorderedDoc417]

Yeah. I’m hearing 7-8 and wondering where this exists. Sign me up! I just want to avoid being told I need to see 20 a day...at least everyday.

 

[NickNaylor]

Yeah. I’m hearing 7-8 and wondering where this exists. Sign me up! I just want to avoid being told I need to see 20 a day...at least everyday.

Academia - at least in our neck of the woods.

 

[Mass Effect]

Academia - at least in our neck of the woods.

Ditto. In academia, 7-10 is the norm in my experience.

 

[Jules A]

Ditto. In academia, 7-10 is the norm in my experience.

For what $200,000 a year and all the prestige of having XYZ University on your CV?

 

[dl2dp2]

I'm not sure hospital admins can "push" you in this way. Just refuse admissions.

1) if they want to fire you you'll find another job immediately, and they'll lose half a year of salary to recruit a new person.

2) if they want to you take any admissions and you are not able to do so, just say no. This can be for any clinical/quality reason.

Realistically right now in psychiatry it's not really feasible for any admin to "push" clinicians to do things they don't want to do. Believe it or not the hospital admin job is way harder, because it's really hard to retain people the minute any kind of "pushing" occurs. More likely than not any amount of "pushing" is just all bluffing. Just politely say no and tell the unit clerk your unit is full.

As some noted above, if you have a production based compensation model, no pushing will be necessary. Hospitals only push because they get pressure from higher ups to see more unprofitable patients. Nobody really cares. It doesn't impact anyone. Nurses will thank you for blocking admissions.

 

[MedMan80]

Kind of a tangent but have you guys seen jobs in academia moving towards a more private model where all the attendings time has to be accounted for? For instance when I was a resident my attendings would see 12 on the inpatient unit with the resident doing most of the work, for the afternoon the attendings were either chilling or seeing their private patients. The jobs i'm interviewing for want me to see patients in the AM with the resident and then see outpatients in the academic centers clinic (no extra $), and the salary is still 200K...

 

[nexus73]

I'm not sure hospital admins can "push" you in this way. Just refuse admissions.

1) if they want to fire you you'll find another job immediately, and they'll lose half a year of salary to recruit a new person.

2) if they want to you take any admissions and you are not able to do so, just say no. This can be for any clinical/quality reason.

Realistically right now in psychiatry it's not really feasible for any admin to "push" clinicians to do things they don't want to do. Believe it or not the hospital admin job is way harder, because it's really hard to retain people the minute any kind of "pushing" occurs. More likely than not any amount of "pushing" is just all bluffing. Just politely say no and tell the unit clerk your unit is full.

As some noted above, if you have a production based compensation model, no pushing will be necessary. Hospitals only push because they get pressure from higher ups to see more unprofitable patients. Nobody really cares. It doesn't impact anyone. Nurses will thank you for blocking admissions.

Thanks for this thought. My concern with declining admissions or consults is this: the hospital bylaws have time expectations for how long until you get to a consult. Med/surg is 24 hours, ED is 18 hours. If we don't admit someone, they sit in the ED and the ED doctor puts in a consult order. So if we decline to see someone and don't (or can't) consult within the time requirements, admin could easily say we're in violation of bylaws and start a disciplinary process. I don't think this would end well for admin, as doctors would almost certainly leave if they took this approach. Does anyone know how likely it is for such a disciplinary action to follow you to your next job? I'd guess it would require a series of bylaw violations, escalating through various consequences and the doctor given several chances to rectify the behavior before it would become something reportable, or become an issue where you'd be losing privileges, I just don't know. But clearly that would be a situation where you'd want to leave the job ASAP.

 

[wolfvgang22]

Won't follow you anymore than getting fired would.

I once saw a complaint to the state med board filed on a friend for refusing to accept a consult, and the state med board investigated and caused him a paperwork headache, but nothing else happened. That doctor was already unpopular with admin for working too slow. That doctor left soon after that. State med board wont do anything if you never saw the patient in the first place, because there is no legislated duty to accept consults.

 

[michaelrack]

Action taken by the hospital against your privileges can definitely follow you

 

[wolfvgang22]

Action taken by the hospital against your privileges can definitely follow you

Good point, state medical boards, insurance, and hospitals usually ask if your privileges have been revoked for any reason.

 

[dl2dp2]

Thanks for this thought. My concern with declining admissions or consults is this: the hospital bylaws have time expectations for how long until you get to a consult. Med/surg is 24 hours, ED is 18 hours. If we don't admit someone, they sit in the ED and the ED doctor puts in a consult order. So if we decline to see someone and don't (or can't) consult within the time requirements, admin could easily say we're in violation of bylaws and start a disciplinary process. I don't think this would end well for admin, as doctors would almost certainly leave if they took this approach. Does anyone know how likely it is for such a disciplinary action to follow you to your next job? I'd guess it would require a series of bylaw violations, escalating through various consequences and the doctor given several chances to rectify the behavior before it would become something reportable, or become an issue where you'd be losing privileges, I just don't know. But clearly that would be a situation where you'd want to leave the job ASAP.

Again this is not an issue. Bylaws don’t matter if it’s intefering with delivering quality patient care. Hospitals can’t discipline you if you are delivery high quality clinical care. If hospitals are not getting consults seen on time it means that it’s understaffed. That problem is above your pay grade. Your job is to deliver the highest quality care to your patients. Focus on that and stop worrying about administrative nonsense.

 

[Mad Jack]

For what $200,000 a year and all the prestige of having XYZ University on your CV?

Also not having to do notes, if you have residents doing all of the notes.

 

[NickNaylor]

For what $200,000 a year and all the prestige of having XYZ University on your CV?

Academia can be much more lucrative than that. That being said, one of the things that accounts for the lower pay - at least in my institution - is having minions (residents) do a lot of the grunt work (documentation) in addition to the much lower volume of patients compared to, say, an inpatient unit at a private system. Around here, private units will expect you to carry double or triple the numbers of patients for roughly equivalent pay. And you're doing all of that work, not a resident.

 

[splik]

Kind of a tangent but have you guys seen jobs in academia moving towards a more private model where all the attendings time has to be accounted for? For instance when I was a resident my attendings would see 12 on the inpatient unit with the resident doing most of the work, for the afternoon the attendings were either chilling or seeing their private patients. The jobs i'm interviewing for want me to see patients in the AM with the resident and then see outpatients in the academic centers clinic (no extra $), and the salary is still 200K...

I realize your post is a little old but I have a few thoughts
1. It would depend on how many inpatients you have, how sick they are, and how often you are required to see them. super psychotic patients and violent patients and I can see 9 in an hour and bash out the all the notes in another hour. more complex patients or patients with personality disorders, mood disorders etc tend to take much longer.
2. 12 patients a day is definitely a full time job if you have to see them all. 10 or more is definitely full time. If you only have 5 or 6 in patients then of course its not full time.
3. Think about what your worst day would look like. For me, on a good day (in terms of relaxed pace) - I see one patient. On a bad day, I have no residents, covering multiple colleagues who are away, covering inpatient, consults, and doing outpatient evals. in addition to everything else. point being, if you had a job to see 10 patients, that easily becomes 15 pts when the other attending is on vacations and there are gonna be times when your residents are at clinic/didactics/nightfloat/vacation etc and you have to do all the work. It would be unworkable to have to do an outpatient clinic under those conditions as well.
4. These people are chancers and eat residents applying for their first job alive. My friend applied for an inpt position at an academic center. The job offer casually mentioned that she would staff the residents clinic. I noticed this when reviewing the letter, and told her to question this. They played dumb and said that faculty "enjoyed" working in the resident clinic so though she might enjoy doing that as well (this was a full time inpatient position). They casually removed it upon her request.
5. More academic centers are moving to an RVU model. In which case, if you have a minimum RVU threshold (usually its much lower in academics - about 3200-3700), then you should receive a productivity bonus if you exceed that. It's actually pretty easy to do on inpatient, and that could make it potentially v worthwhile to do an inpt/outpt mix if you want to work hard and be compensated for it. But they may not mention this unless you make a thing of it because they are chancers.
6. Think of the recruitment process as a taster of how you will be treated in the job. If you get the sense they are trying to exploit you, that is a good indication you are going to be exploited later on.

 

[MedMan80]

I realize your post is a little old but I have a few thoughts
1. It would depend on how many inpatients you have, how sick they are, and how often you are required to see them. super psychotic patients and violent patients and I can see 9 in an hour and bash out the all the notes in another hour. more complex patients or patients with personality disorders, mood disorders etc tend to take much longer.
2. 12 patients a day is definitely a full time job if you have to see them all. 10 or more is definitely full time. If you only have 5 or 6 in patients then of course its not full time.
3. Think about what your worst day would look like. For me, on a good day (in terms of relaxed pace) - I see one patient. On a bad day, I have no residents, covering multiple colleagues who are away, covering inpatient, consults, and doing outpatient evals. in addition to everything else. point being, if you had a job to see 10 patients, that easily becomes 15 pts when the other attending is on vacations and there are gonna be times when your residents are at clinic/didactics/nightfloat/vacation etc and you have to do all the work. It would be unworkable to have to do an outpatient clinic under those conditions as well.
4. These people are chancers and eat residents applying for their first job alive. My friend applied for an inpt position at an academic center. The job offer casually mentioned that she would staff the residents clinic. I noticed this when reviewing the letter, and told her to question this. They played dumb and said that faculty "enjoyed" working in the resident clinic so though she might enjoy doing that as well (this was a full time inpatient position). They casually removed it upon her request.
5. More academic centers are moving to an RVU model. In which case, if you have a minimum RVU threshold (usually its much lower in academics - about 3200-3700), then you should receive a productivity bonus if you exceed that. It's actually pretty easy to do on inpatient, and that could make it potentially v worthwhile to do an inpt/outpt mix if you want to work hard and be compensated for it. But they may not mention this unless you make a thing of it because they are chancers.
6. Think of the recruitment process as a taster of how you will be treated in the job. If you get the sense they are trying to exploit you, that is a good indication you are going to be exploited later on.

Thanks for the great advice, thankfully I’ve signed already. Regarding the rvu, the place was willing to adjust the salary after the second year but it didn’t seem to be a potential significant bump. I just felt like most academic places were busier than I was used to seeing with my Attending’s. It is possible they were trying to exploit my freshness or visa needs..

 

[DoctrCatLady]

There's a residency program that I've visited that has a patient cap of 16 patients. It seems like a lot to me but they say they have very strong ancillary staff to help with collaterals, disposition, etc so you can focus on patient care. What are your thoughts about this program? Is 16 patients a red flag or will I still be able to learn properly from each patient?

 

[Sushirolls]

I'm an attending, and even with amazing unit staff, and me opting to work in a fashion I'm at 110% optimization, 16 is a lot.
As a resident being tasked with doing collateral and some of the SW or unit clerk tasks can actually be informative and help you to understand what makes a unit tic, so when the time comes you are an attending and eventual medical director you understand the nuances of the jobs.
Personally, what I know now, I'd avoid a program that has a 16 pt cap.

You want to have a slower pace, so when with the attending you can ask the nuanced questions about the MSE. "Yo, Doc Boss, I put this patient down as tangential, do you agree?" "No young Dr Cat Lady, this patient would probably be better described as ... and this is why..."
"Yo, Doc Boss, I'm thinking of starting this patient at Seroquel 100mg QHS, do you agree with this?" "Young Dr Cat Lady, this could work for this patient, but could you present an alternative antipsychotic to start and explain your reasoning for choosing it?"

You want to have the time pick questions and get nuanced answers. As a resident, I sat an old doc down one time, recorded his experience and descriptions about all the typical antipsychotics and squeezed out every kernel of information I could. Transcribed it, and shared with some residents. You should have the time to do these things.

 

[clausewitz2]

I'm an attending, and even with amazing unit staff, and me opting to work in a fashion I'm at 110% optimization, 16 is a lot.
As a resident being tasked with doing collateral and some of the SW or unit clerk tasks can actually be informative and help you to understand what makes a unit tic, so when the time comes you are an attending and eventual medical director you understand the nuances of the jobs.
Personally, what I know now, I'd avoid a program that has a 16 pt cap.

You want to have a slower pace, so when with the attending you can ask the nuanced questions about the MSE. "Yo, Doc Boss, I put this patient down as tangential, do you agree?" "No young Dr Cat Lady, this patient would probably be better described as ... and this is why..."
"Yo, Doc Boss, I'm thinking of starting this patient at Seroquel 100mg QHS, do you agree with this?" "Young Dr Cat Lady, this could work for this patient, but could you present an alternative antipsychotic to start and explain your reasoning for choosing it?"

You want to have the time pick questions and get nuanced answers. As a resident, I sat an old doc down one time, recorded his experience and descriptions about all the typical antipsychotics and squeezed out every kernel of information I could. Transcribed it, and shared with some residents. You should have the time to do these things.

So true. Our field is so easy to half-ass that I think if you are training in a high volume place you end up thinking you are far more competent and knowledgeable than you really are. One of the attendings at our shop runs a very high turnover, high volume service, and his main talents is quickly grasping about 85% of the situation of a given patient. Most of the time this ends up being...fine, but when that 15% missing is important it is a serious problem. For example, deciding a patient is malingering when their interview is really vague and planning to discharge to a homeless shelter -> more collateral and cognitive assessment leads to a dementia diagnosis and discharge to a SNF.

 

[Merovinge]

There's a residency program that I've visited that has a patient cap of 16 patients. It seems like a lot to me but they say they have very strong ancillary staff to help with collaterals, disposition, etc so you can focus on patient care. What are your thoughts about this program? Is 16 patients a red flag or will I still be able to learn properly from each patient?

Huge red flag for me. That cap is so high for a resident, the fact they even list it at all makes the social pressure on everyone that 16 is a reasonable number for you. You need to do some of the "ancillary" work as a resident to really understand your work and the field (i.e. talk to patient's families, their outpatient docs, understand disposition). I'd be shocked if this program wasn't a non-competitive program looking for desperate residents trying to match psychiatry.

 

[FlowRate]

There's a residency program that I've visited that has a patient cap of 16 patients. It seems like a lot to me but they say they have very strong ancillary staff to help with collaterals, disposition, etc so you can focus on patient care. What are your thoughts about this program? Is 16 patients a red flag or will I still be able to learn properly from each patient?

16 is more than double what our stated cap was as PGY2's. While we sometimes "broke" cap if we otherwise felt compensated, I usually felt busy enough with 6 (and minimal help from the overworked social workers and under-tasked psychology interns; if they're the "primary clinician" then why can't they write the non-medical parts of the discharge summary?)

 

[Mass Effect]

There's a residency program that I've visited that has a patient cap of 16 patients. It seems like a lot to me but they say they have very strong ancillary staff to help with collaterals, disposition, etc so you can focus on patient care. What are your thoughts about this program? Is 16 patients a red flag or will I still be able to learn properly from each patient?

Let me guess, this is in NYC?

 

[DoctrCatLady]

Let me guess, this is in NYC?

Surprisingly not actually! This one isn't in the Northeast

 

[Merely]

I'm an attending, and even with amazing unit staff, and me opting to work in a fashion I'm at 110% optimization, 16 is a lot.
As a resident being tasked with doing collateral and some of the SW or unit clerk tasks can actually be informative and help you to understand what makes a unit tic, so when the time comes you are an attending and eventual medical director you understand the nuances of the jobs.
Personally, what I know now, I'd avoid a program that has a 16 pt cap.

You want to have a slower pace, so when with the attending you can ask the nuanced questions about the MSE. "Yo, Doc Boss, I put this patient down as tangential, do you agree?" "No young Dr Cat Lady, this patient would probably be better described as ... and this is why..."
"Yo, Doc Boss, I'm thinking of starting this patient at Seroquel 100mg QHS, do you agree with this?" "Young Dr Cat Lady, this could work for this patient, but could you present an alternative antipsychotic to start and explain your reasoning for choosing it?"

You want to have the time pick questions and get nuanced answers. As a resident, I sat an old doc down one time, recorded his experience and descriptions about all the typical antipsychotics and squeezed out every kernel of information I could. Transcribed it, and shared with some residents. You should have the time to do these things.

do you still have those notes lol