Occupational trauma

[meow1985]

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I read Bessel van der Kolk's "The Body Keeps the Score," and I've realized that I have trauma reactions about my job all the time.

My state is a disconnect between the role I play, that of the confident, calm, self-assured specialist who can keep their head in a crisis and come up with a solution, and the person that I am, who feels constantly in danger and ill-equipped to do much of anything. Not physical danger per se, but professional and emotional danger. In physical danger, I know what to do, just get the heck out and call security. Emotional and professional danger is more complicated. Patients angry at you, patients complaining, or simply going into a situation and not being able to come up with a plan, or bungling things under pressure. A bad outcome resulting in an institutional investigation, a board investigation, a lawsuit, or simply colleagues' censure. That kind of danger. In the end everything usually works out and I am able to come up with some reasonable intervention, but somehow that doesn't "teach" me that yes, I am capable, and yes, everything will probably be alright.

I changed to a job with a slightly more stable, worried well population, but suicidal, homicidal, substance abusing, and capacity-lacking patients are everywhere. I feel unsafe when I know I am responsible for their violent and self-harming behaviors, yet am ill-equipped to mitigate the risk.

Switching jobs helped, since now at least my staff doesn't give me pushback when I ask them to do something.

I spend my days off self soothing myself back to a state where I'm ready to face it all again. Working less is not a solution because I just worry about all the fires I'm not there to put out - though, again, with more reliable coverage and support staff at new job this has improved a bit.

My therapist is unhelpful. He is an older private practice MD who does mostly therapy. I thought he'd be able to understand what I am going through, and he does, but all he does by way of counsel is pontificate about his fringey views and how jaded modern psychiatry makes him. I tried giving him feedback, but that hasn't helped. I might need to find a different therapist.

Idk what to do. Looking for perspective or guidance, I guess.

 

[AD04]

Internalize these thoughts:

1. If someone who is less capable than you (maybe a colleague from residency or the old psychiatrist who has not kept up to date) can do this, then you can do it too.

2. If they reprimand you and drive you away, who is going to do the work? Because you are harder to replace, you can get away with quite a bit. It is easier for you to get another job than for them to find another psychiatrist.

3. Base your satisfaction in yourself based on what you did, not on the outcome. Sometimes there are patients you cannot help. You did what you can. People make their own choices and there are things even you can't control.

If you want to get more comfortable that you're not perfect, conduct you own exposure therapy and start by being deliberately imperfect in little but inconsequential ways at work. Most likely you'll see that you care way more than others. If you're doing something wrong and they care that you're doing something wrong, they'll let you know.

Will worrying add another day to your life? If not, why spend so much energy worrying?

 

[FlowRate]

My therapist is unhelpful. He is an older private practice MD who does mostly therapy. I thought he'd be able to understand what I am going through, and he does, but all he does by way of counsel is pontificate about his fringey views and how jaded modern psychiatry makes him. I tried giving him feedback, but that hasn't helped. I might need to find a different therapist.

Good on you for getting started in therapy and also seeking a more supportive job! Real bummer when your therapist is just not a good fit. You've done the hardest part by trying to give feedback but unfortunately the therapist didn't respond in a way that led to a deepening of your relationship. I hope the next therapist is a good fit.

I feel unsafe when I know I am responsible for their violent and self-harming behaviors, yet am ill-equipped to mitigate the risk.

You are not responsible for their behaviors, you're responsible for providing the standard of medical care that aims to reduce the risk of those behaviors. Do you know what your average colleague would do in any given situation? Are you doing something at least as useful as that? Good, you're all set.

 

[deleted1100659]

1. The minute someone raises their voice to me, interview ended I refuse to see them unless they calm down. I don't risk any escalation. Not worth my safety. Keep in mind, as a psychiatrist you are a highly valuable asset, there isnt many of us. That gives you some negotiation power.

2. I am a firm believer in quality care with a side of cover your ass medicine. I dont take unnecessary risks. If something is even least bit risky i document extensively why im doing it, pt consented and has capacity to give consent, explained possible outcomes but this treatment is necessary at this time given xxxx. Your goal is to help the patient, but never at the cost of dooming your career.

3. I set limits/rules with patients. I stick to these rules. Everyone who walks in my office gets the same level of care/treatment.

4. Most of my patients are high acuity patients (active substance use, multiple medical issues, etc). You give advice, document the advice you gave, but ultimately its up to the pt to take it, you can't force them.

5. If they are an active threat to themself or others, then its involuntary hold. That's how you sleep at night. Once someone starts throwing out SI w/ plan, im hard pressed to let them leave. If the hospital ER or facility wants to discharge them, then thats on them, but we have to take active threats seriously.

I had a patient a week ago on xanax, klonopin and lithium prescribed by their PCP with no lithium levels. If this guy is still in practice, I think you will probably be ok.

Also, im sure you're doing a much better job than you realize. Maybe do something nice for yourself. Go on a nice vacation. Get a car. Treat yourself. Its how I stay sane, personally.

 

[comp1]

I'm not sure where you are in your career, but regardless, I want you to keep some hope. I feel like I was there about five years ago and if you're in the right supportive work environment, things get better. You'll still make mistakes and people will complain, but there will come a point where they don't crush you. For me at least, it felt like weight lifting. Working in an environment that isn't supportive or is isolating is going to be sort of like overtraining and you are hurting yourself, but a supportive working environment will build you up. If your colleagues aren't supportive, if it isn't a place where you can always run ideas about treatment by each other, leave. I definitely second the above poster, if you're halfway competent and most people with your level of concern are, your employer needs you a lot more than you need them.

 

[ridethecliche]

I feel unsafe when I know I am responsible for their violent and self-harming behaviors, yet am ill-equipped to mitigate the risk.

Are you really though?

I agree that you need to see a different therapist. Maybe someone with more therapy oriented training. Tbh if I'm looking for a therapist in the future, I probably won't be seeing an MD unless they've done outside training or focus on it more.

 

[clausewitz2]

If you want to get more comfortable that you're not perfect, conduct you own exposure therapy and start by being deliberately imperfect in little but inconsequential ways at work. Most likely you'll see that you care way more than others. If you're doing something wrong and they care that you're doing something wrong, they'll let you know.

I think this might be a very beneficial exercise for the OP. An easy way to start implementing this might be by, say, deliberately misspelling highly visible words in your notes, e.g. names of medications. No one is going to be able to sue you for malpractice for bad spelling but it is still going to be quite obvious (to you, at least). don't tell anyone at work that you are planning to do this or are doing it. Try it for a month and see what happens.

In general this sounds a lot more like you are struggling with a great deal of anxiety than trauma per se. I second others in saying seeking out a therapist who knows their stuff when it comes to evidence-based treatment of anxiety is the best bang for your buck here.

 

[Nines]

I can relate to this. The constant anxiety of something going wrong and me causing a patient harm accidentally or the fear that I am inadequate. Sometimes these fears are reinforced by patients not getting better or having some kind of side effect or crisis and sometimes they are disputed by patients improving and being grateful for my care. Its a roller coaster! Physicians can have anxiety disorders too! Sometimes certain therapy modalities are less helpful so getting a new therapist may be a good idea. Overall a few things i have found that helped

1) Working a 4 day week. Having that three day weekend every weekend is so beneficial. Even though I work 40 hours it makes my life feel less consumed by work. Can do weekend trips etc too without using PTO.

2) Having good staff who I trust. Especially the nurse/ma who is taking patient phone calls etc. I am very lucky in that department and it really helps immensely. Looks like you hopefully have better staff in your new job.

3) Trying to let go of what I can't control. This is hard and I still struggle with this as an anxious person. Its gotten easier as of the start of year 2 in my first outpatient job. Time and perspective help as you get used to the work.

4) Realizing that situations tend to repeat themselves. I mean that similar situations will occur with different patients again and again. There are only so many permutations of crises/problems that can occur! As you deal with them again and again you will feel much more competent dealing with it as you have successfully dealt with that scenario before.

Some can do this work with minimal anxiety and others just can't. But it can get manageable for sure.

 

[Candidate2017]

My state is a disconnect between the role I play, that of the confident, calm, self-assured specialist who can keep their head in a crisis and come up with a solution, and the person that I am, who feels constantly in danger and ill-equipped to do much of anything.

Well, yeah. Being a psychiatrist means you do have to accept that you really can't do all that much. Most of it is up to the patient, with some contributing factors from their support system and society.

 

[hallowmann]

I think this might be a very beneficial exercise for the OP. An easy way to start implementing this might be by, say, deliberately misspelling highly visible words in your notes, e.g. names of medications. No one is going to be able to sue you for malpractice for bad spelling but it is still going to be quite obvious (to you, at least). don't tell anyone at work that you are planning to do this or are doing it. Try it for a month and see what happens.

In general this sounds a lot more like you are struggling with a great deal of anxiety than trauma per se. I second others in saying seeking out a therapist who knows their stuff when it comes to evidence-based treatment of anxiety is the best bang for your buck here.

This was literally the recommendation an attending had told me in PGY2 to encourage me to spend less time on documentation. Misspell words on purpose.

I can't say I actually committed to it, but I'm definitely less picky and more efficient than I was then.

 

[meow1985]

This was literally the recommendation an attending had told me in PGY2 to encourage me to spend less time on documentation. Misspell words on purpose.

I can't say I actually committed to it, but I'm definitely less picky and more efficient than I was then.

I think that's good advice, and I've started to do that. It does take effort, but I can leave misspellings, typos or formatting weirdness as long as I feel like the note is generally readable. I also type in session and when I go back I try to edit as little as possible - hang the fact that it's barely English at times. That part's tougher, though.

The real exposure therapy I need is to not over-explain, but just like @DrAmazingishere I tend to feel the need to be defensive in my documentation by thinking of what holes can a lawyer or particularly risk-averse colleague pick in my plan. Said defensive documentation leaves me doing 3+ hours of note-writing every day. And that's WITH a template, dictating, dot phrases for side effects "spiels" I typically give patients, and typing in session. I basically have no life on weekdays as a result.

For example, let's say I inherit a patient who is on bupropion despite a remote history of eating disorder. My documentation may go like this:

"Patient has remote hx of bulimia. He also has long-term stability on bupropion XL, which is more effective and better tolerated than multiple other agents tried. Discussed FDA contraindication of bupropion in context of bulimia due to seizure risk, and agreed it's in patient's best interest to continue the medication. We agreed that patient will promptly report any signs and symptoms of bulimia recurrence, and in that event will stop medication. In addition, bupropion XL has less risk of seizure than bupropion IR, which was studied leading to the FDA warning."

But honestly it should probably be something like this:
"Discussed FDA warning of seizure risk with bupropion given hx of bulimia. Bupropion benefits currently outweigh risks. Will stop med if bulimia recurs."

But the latter version is rather painful to write and would only be something I'd do if I'm dead tired and have stopped caring.

 

[Bartelby]

The second description (in the context of the broader chart, which would presumably already have information about the patient's long-term stability on Wellbutrin) seems to provide just as much liability protection and is easier to read. I think it is actually better than the first. Getting comfortable with good-enough charting has the potential to help out a fair amount I think.

 

[hallowmann]

I think that's good advice, and I've started to do that. It does take effort, but I can leave misspellings, typos or formatting weirdness as long as I feel like the note is generally readable. I also type in session and when I go back I try to edit as little as possible - hang the fact that it's barely English at times. That part's tougher, though.

The real exposure therapy I need is to not over-explain, but just like @DrAmazingishere I tend to feel the need to be defensive in my documentation by thinking of what holes can a lawyer or particularly risk-averse colleague pick in my plan. Said defensive documentation leaves me doing 3+ hours of note-writing every day. And that's WITH a template, dictating, dot phrases for side effects "spiels" I typically give patients, and typing in session. I basically have no life on weekdays as a result.

For example, let's say I inherit a patient who is on bupropion despite a remote history of eating disorder. My documentation may go like this:

"Patient has remote hx of bulimia. He also has long-term stability on bupropion XL, which is more effective and better tolerated than multiple other agents tried. Discussed FDA contraindication of bupropion in context of bulimia due to seizure risk, and agreed it's in patient's best interest to continue the medication. We agreed that patient will promptly report any signs and symptoms of bulimia recurrence, and in that event will stop medication. In addition, bupropion XL has less risk of seizure than bupropion IR, which was studied leading to the FDA warning."

But honestly it should probably be something like this:
"Discussed FDA warning of seizure risk with bupropion given hx of bulimia. Bupropion benefits currently outweigh risks. Will stop med if bulimia recurs."

But the latter version is rather painful to write and would only be something I'd do if I'm dead tired and have stopped caring.

3 hours a day after work is not sustainable. Maybe 1 hour (e.g. finish by 6 pm), but not 3. Imaging having a family and working 11-12 hrs a day on weekdays. Its a recipe to burnout. I agree that the second summary is what you should be writing. It relays your concerns more clearly and provides you with the same protection you would have in case of malpractice. This should not be the painful way to write, this should be what you are doing, and honestly its more than a lot of psychiatrists write.

I tried a few different methods of cutting down charting time, and I've noticed that if I have 5-10 min in between patients, it actually makes it the most efficient for me to write the note. Basically dictate or type in-between patients with a goal of being done with the note before you see the next one. Its usually a bit faster, because everything is fresh in your mind as well. See if you can adjust to fit that in. That way, you are only using after work time to catch up or for reviewing information/results for patients.

Doing the morning notes at lunch is another way that's worked for me, but that means I lose my lunch which also means I make worse decisions for dinner.

 

[Mass Effect]

I think that's good advice, and I've started to do that. It does take effort, but I can leave misspellings, typos or formatting weirdness as long as I feel like the note is generally readable. I also type in session and when I go back I try to edit as little as possible - hang the fact that it's barely English at times. That part's tougher, though.

The real exposure therapy I need is to not over-explain, but just like @DrAmazingishere I tend to feel the need to be defensive in my documentation by thinking of what holes can a lawyer or particularly risk-averse colleague pick in my plan. Said defensive documentation leaves me doing 3+ hours of note-writing every day. And that's WITH a template, dictating, dot phrases for side effects "spiels" I typically give patients, and typing in session. I basically have no life on weekdays as a result.

For example, let's say I inherit a patient who is on bupropion despite a remote history of eating disorder. My documentation may go like this:

"Patient has remote hx of bulimia. He also has long-term stability on bupropion XL, which is more effective and better tolerated than multiple other agents tried. Discussed FDA contraindication of bupropion in context of bulimia due to seizure risk, and agreed it's in patient's best interest to continue the medication. We agreed that patient will promptly report any signs and symptoms of bulimia recurrence, and in that event will stop medication. In addition, bupropion XL has less risk of seizure than bupropion IR, which was studied leading to the FDA warning."

But honestly it should probably be something like this:
"Discussed FDA warning of seizure risk with bupropion given hx of bulimia. Bupropion benefits currently outweigh risks. Will stop med if bulimia recurs."

But the latter version is rather painful to write and would only be something I'd do if I'm dead tired and have stopped caring.

I don't understand something. So you had a pt on bupropion with remote hx of bulimia. Great. But you documented it (and agree the second one is better) so from then on, all you have to do is carry it forward in your note, right? You don't need to type that over again. Every single patient doesn't have that kind of thing in their hx, right? Outpt is a mix of new pts and follow ups and the follow ups should be fairly easy documentation wise, assuming stability. So why is it taking 3 hours a night?

 

[meow1985]

I tried a few different methods of cutting down charting time, and I've noticed that if I have 5-10 min in between patients, it actually makes it the most efficient for me to write the note. Basically dictate or type in-between patients with a goal of being done with the note before you see the next one. Its usually a bit faster, because everything is fresh in your mind as well. See if you can adjust to fit that in. That way, you are only using after work time to catch up or for reviewing information/results for patients.

3 hours is NOT sustainable. That's why I hate my life, lol.

And the other problem is, unless my patients are stable and/or uncomplicated, which is more the exception than the rule, I do not have time in between patients. To make the patient feel heard, assess for the relevant things, decide on a plan, discuss side effects in a more than cursory way, and answer all their questions, 30 minutes is barely enough. And if I do have time between patients, I usually need to take those 5-10 minutes to deep-breathe because I'm stressed after having seen the chronically suicidal patient earlier that day, or the patient who has no good solution to their problem or the person who no matter what you try, it's high risk, or talk myself down from second-guessing some tough decision I make 2 patients ago. 🙁

 

[meow1985]

I don't understand something. So you had a pt on bupropion with remote hx of bulimia. Great. But you documented it (and agree the second one is better) so from then on, all you have to do is carry it forward in your note, right? You don't need to type that over again. Every single patient doesn't have that kind of thing in their hx, right? Outpt is a mix of new pts and follow ups and the follow ups should be fairly easy documentation wise, assuming stability. So why is it taking 3 hours a night?

That's a good question!

As far as I can tell, it's a few things:

1) editing what I typed down in session so it "makes more sense." Completing incomplete or unclear sentences, and copy-pasting different parts of history are in the right part of the note if necessary

2) I have noticed that if I'm doing something halfway controversial or higher risk, my documentation balloons to what you saw in the bupropion example or even more. Certainly it's not *every* patient, but there are lots of things we do in our field that may be questionable according to the textbook, but make sense in context. Even outside of that, I feel the need to explain why I did this but not that, or why I did things at all, i.e. "stopping bupropion because this will likely help sleep and anxiety."

2.5) A lot of my patients are new or not yet stable at this time, since I am new in my current job.

Other things
3) "Wait, should I call this diagnosis A or closely related diagnosis B? Let me check the HPI again"

4) Clicking all the things in Epic.

5) "Wait, did I write the prescription exactly the same as I wrote the plan? Let me check again"


Generally, if a patient encounter was stressful, or involved something more complicated or high risk, I will have done less of items 3-5 in session, and so need to do more outside of session. Documenting about a more stressful encounter also makes it hard to *just document* since I am basically re-experiencing all the stress of the encounter in that moment. I then end up over-documenting as a coping mechanism.

 

[Mass Effect]

That's a good question!

As far as I can tell, it's a few things:

1) editing what I typed down in session so it "makes more sense." Completing incomplete or unclear sentences, and copy-pasting different parts of history are in the right part of the note if necessary

Editing what you wrote in session should be just a matter of finishing sentences. Keep in mind, your notes don't have to have complete sentences.

"Johnny reports that his sleep is about 7 hours, but he says that he gets up 3 times a night due to nightmares"

is just as correct as...

"Sleeps 7 hours. Disrupted X 3 d/t nightmares".

For the formulation you want to write more complete sentences and formulation can be carried over and updated, but you have to let go of the mindset that you're writing a book. The only reason we write notes is to document the encounter for safety and billing, not to pretty it up or write a dissertation on the person's life.

Speaking of that, a mistake I see a lot of people make is writing out all the dramas in the person's life. "Johnny reports that his sleep is about 7 hours, but he says that he gets up 3 times a night due to nightmares. He also had a fight with his girlfriend over where they would vacation and that has been causing him hurt feelings and stress that is also affecting his sleep".

Totally unnecessary and inappropriate. The note should read "Sleeps 7 hours. Disrupted X 3 d/t nightmares and romantic stressor".

Not only does it increase documentation time to spell out every stressor our patients have, but it also leads to garbage in the note that hides useful information AND it lets PCP or others know intimate details of the patient's life that are not important to the care they're providing.

2) I have noticed that if I'm doing something halfway controversial or higher risk, my documentation balloons to what you saw in the bupropion example or even more. Certainly it's not *every* patient, but there are lots of things we do in our field that may be questionable according to the textbook, but make sense in context. Even outside of that, I feel the need to explain why I did this but not that, or why I did things at all, i.e. "stopping bupropion because this will likely help sleep and anxiety."

That's ok to explain things. The point is to summarize what you're explaining. In the bupropion example, all you need to say is "discussed sz risk which is increased with ED, but pt's ED hx is remote and benefit outweighs risk at this time". You don't have to explain every single thing. The only thing you need to do from a liability standpoint is just demonstrate you thought about it and discussed it.

Other things
3) "Wait, should I call this diagnosis A or closely related diagnosis B? Let me check the HPI again"

I assume you mean between closely related things within the same class? Like MDD vs depression unspecified? The dx is needed for billing, but in most cases, it won't affect treatment. The bottom line is the patient is depressed. Now if you're debating between MDD and bipolar, that does make a difference and you need to figure it out. But for things that are closely related, you should not be spending more than 2 minutes assigning a dx and even 2 minutes too 1:30 too long.

5) "Wait, did I write the prescription exactly the same as I wrote the plan? Let me check again"

This is just anxiety/OC(P?)D traits (I'm not diagnosing you of course). But you just need to stop it! 😉 But seriously, how many times have you done it differently or have you been wrong? I'm going to guess 0.

 

[Mass Effect]

3 hours is NOT sustainable. That's why I hate my life, lol.

And the other problem is, unless my patients are stable and/or uncomplicated, which is more the exception than the rule, I do not have time in between patients. To make the patient feel heard, assess for the relevant things, decide on a plan, discuss side effects in a more than cursory way, and answer all their questions, 30 minutes is barely enough. And if I do have time between patients, I usually need to take those 5-10 minutes to deep-breathe because I'm stressed after having seen the chronically suicidal patient earlier that day, or the patient who has no good solution to their problem or the person who no matter what you try, it's high risk, or talk myself down from second-guessing some tough decision I make 2 patients ago. 🙁

You have to get more efficient here. This isn't a suggestion. It's a must, unless you plan to work for yourself and you're ok not making much money. The patient WILL feel heard after 30 min. If a PCP can hear an entire CHF story in 15 minutes and make the pt feel heard, we can do it in 30 for follow ups. You should role play with someone you trust. If you can't make the convo flow appropriately, then you should have a checklist depending on the person. At the top of your note template, just have a spot for mood, anxiety, sleep, appetite, safety, medications, side effects/compliance. Run through those one by one when the patient comes in if you have to. For most patients, you'll get through that list in 15 minutes leaving another 15 minutes for treatment planning, if needed. Once you do that a few times, you'll be able to hold a conversation rather than a checklist, but you should do the checklist to become efficient at getting the information you need to get.

 

[meow1985]

Editing what you wrote in session should be just a matter of finishing sentences. Keep in mind, your notes don't have to have complete sentences.

"Johnny reports that his sleep is about 7 hours, but he says that he gets up 3 times a night due to nightmares"

is just as correct as...

"Sleeps 7 hours. Disrupted X 3 d/t nightmares".

For the formulation you want to write more complete sentences and formulation can be carried over and updated, but you have to let go of the mindset that you're writing a book. The only reason we write notes is to document the encounter for safety and billing, not to pretty it up or write a dissertation on the person's life.



That's ok to explain things. The point is to summarize what you're explaining. In the bupropion example, all you need to say is "discussed sz risk which is increased with ED, but pt's ED hx is remote and benefit outweighs risk at this time". You don't have to explain every single thing. The only thing you need to do from a liability standpoint is just demonstrate you thought about it and discussed it.




I assume you mean between closely related things within the same class? Like MDD vs depression unspecified? The dx is needed for billing, but in most cases, it won't affect treatment. The bottom line is the patient is depressed. Now if you're debating between MDD and bipolar, that does make a difference and you need to figure it out. But for things that are closely related, you should not be spending more than 2 minutes assigning a dx and even 2 minutes too 1:30 too long.



This is just anxiety/OC(P?)D traits (I'm not diagnosing you of course). But you just need to stop it! 😉 But seriously, how many times have you done it differently or have you been wrong? I'm going to guess 0.

The most important part I think is this, though: “Documenting about a more stressful encounter also makes it hard to *just document* since I am basically re-experiencing all the stress of the encounter in that moment. I then end up over-documenting as a coping mechanism.”

And I get stressed about a lot of my encounters, second guessing or worrying I’d not done enough, or just feeling really icky if the patient is particularly prone to cluster B tactics. I need to work on being ocpd in my notes as a coping mechanism.

I’ve had several instances of inconsistencies between the plan and the script over my career that were caught by someone else. But yeah, I’ve also had thousands of patient encounters so the percentage is very small.

 

[Mass Effect]

The most important part I think is this, though: “Documenting about a more stressful encounter also makes it hard to *just document* since I am basically re-experiencing all the stress of the encounter in that moment. I then end up over-documenting as a coping mechanism.”

And I get stressed about a lot of my encounters, second guessing or worrying I’d not done enough, or just feeling really icky if the patient is particularly prone to cluster B tactics. I need to work on being ocpd in my notes as a coping mechanism.

I’ve had several instances of inconsistencies between the plan and the script over my career that were caught by someone else. But yeah, I’ve also had thousands of patient encounters so the percentage is very small.

What do you consider a stressful encounter? Like if someone came in and is crying because they lost their job, would that be stressful to you? Or are we talking more like someone coming in and being actively suicidal or homicidal?

I want to ask you a serious question not to be mean to try to figure this out. Do you feel like your foundational knowledge is good? Do you know psychiatry, the diagnoses, what you can and can't do, where your responsibility begins and ends? If the answer is yes, then I don't get why you're so stressed about the encounters. We all have some stressful encounters, but when most encounters are that way, we start to worry about other things going on. If you don't have a good foundation, then learning the DSM cover to cover with Stahls nearby is a good start.

 

[meow1985]

You have to get more efficient here. This isn't a suggestion. It's a must, unless you plan to work for yourself and you're ok not making much money. The patient WILL feel heard after 30 min. If a PCP can hear an entire CHF story in 15 minutes and make the pt feel heard, we can do it in 30 for follow ups. You should role play with someone you trust. If you can't make the convo flow appropriately, then you should have a checklist depending on the person. At the top of your note template, just have a spot for mood, anxiety, sleep, appetite, safety, medications, side effects/compliance. Run through those one by one when the patient comes in if you have to. For most patients, you'll get through that list in 15 minutes leaving another 15 minutes for treatment planning, if needed. Once you do that a few times, you'll be able to hold a conversation rather than a checklist, but you should do the checklist to become efficient at getting the information you need to get.

I said if things are more complicated or more high risk, 30 minutes is barely enough.

If things are low-to-medium complicated and the patient isn't the biggest talker in the world, I can even do 20 minutes or less. But right now that situation is not common in my practice.

But if it's one of the one who can't stop talking, or if there's a crisis or other WTF situation, or they're super anxious about side effects or find a problem with every suggestion, then yeah, I run up against that 30 minute timeframe. In fact, in WTF situation my defense mechanism is to start gathering more information in hopes that it will make me feel better about whatever solution I provide. I need not not do that, maybe.

 

[meow1985]

What do you consider a stressful encounter? Like if someone came in and is crying because they lost their job, would that be stressful to you? Or are we talking more like someone coming in and being actively suicidal or homicidal?

I want to ask you a serious question not to be mean to try to figure this out. Do you feel like your foundational knowledge is good? Do you know psychiatry, the diagnoses, what you can and can't do, where your responsibility begins and ends? If the answer is yes, then I don't get why you're so stressed about the encounters. We all have some stressful encounters, but when most encounters are that way, we start to worry about other things going on. If you don't have a good foundation, then learning the DSM cover to cover with Stahls nearby is a good start.

I've been told my base of knowledge is good, and I've always done well on tests, including in psychiatry specifically. But I find it stressful that I know what is textbook-right but the real world doesn't work like that, and the things I know to be textbook-right are hard to implement.

This also ties into what I consider a stressful encounter. Basically, it's when I tell patients what I think should happen, and they refuse. Or when they disagree with the diagnosis or are in denial. Or when patients are chronically doing high-risk things and refuse to change or go into recommended treatment. And then I am faced with a choice. I can tell them we can't work together, or force-taper them from whatever they're on from before that I don't think is a good idea, or... Well, you know, try to find a compromise or a plan that is the lesser of the evils.

PS: Oh yeah and I worry excessively about side effects. When I try to come up with a plan, I often find myself playing mental chess with risk factors that I over-estimate, and end up boxing myself in a corner. I'm like "can't do this, can't do that, can't do this other thing, don't have enough experience with that, help me...."

So what I basically have to do is, in parallel with the conversation with the patient, I need to expend a fair bit of effort to keep my cool and a rational perspective. If they're out the door early, I need to decompress from that. Or I cope by making sure the history-taking and discussion is as thorough as it can be in the time I have. Either way, there's no time for notes. 🙁

I also get stressed when the patient's been on a lot of meds and they are running out of options. Because that means there will come a time when I have to tell them that maybe their problem can't be solved by meds... and they're likely not to like that.

tl;dr it’s conflict and risk, of which I have an over inflated sense.

 

[meow1985]

If a PCP can hear an entire CHF story in 15 minutes and make the pt feel heard, we can do it in 30 for follow ups.

That is debatable actually. Don’t know about PCPs in particular, but I’ve had patients complain to me about the work of my more “efficient” colleagues. On the other hand, I get positive feedback from my patients - “I’ve never had someone take the time to explain things so well,” “thank you for being so candid about the risks,” “you took the time to really get to the bottom of what’s going on with me.” It’s hard because whatever I’ve got I don’t want to lose.

The patients who talk a lot are stressful too by the way. I either have to risk running late and displeasing all my other patients, or interrupt and cut them off, which feels like stepping on a kitten.

 

[watto]

This is way out of left field, but have you considered something like working in hospice care? Doing late-life geri work? Where the frame is perhaps more limited, the work more straightforward, and the goals of treatment less broad? Where you might be more focused on reducing medication burden. Palliative care psychiatry is a growing field.

It also would force you to see the limits of your control, and possibly free you of the self-imposed burdens you place on yourself.

 

[clausewitz2]

OP, it's interesting that you mention struggling with patients who have a reason why any suggestion you make is not going to work.


What do you think is happening in this conversation?

 

[Mass Effect]

That is debatable actually. Don’t know about PCPs in particular, but I’ve had patients complain to me about the work of my more “efficient” colleagues. On the other hand, I get positive feedback from my patients - “I’ve never had someone take the time to explain things so well,” “thank you for being so candid about the risks,” “you took the time to really get to the bottom of what’s going on with me.” It’s hard because whatever I’ve got I don’t want to lose.

The patients who talk a lot are stressful too by the way. I either have to risk running late and displeasing all my other patients, or interrupt and cut them off, which feels like stepping on a kitten.

But that's the thing. What patients consider a good doctor isn't always a good doctor. That isn't to say you're not a good doctor because I have no doubt you are. But basing that on patient perception is wrong. OF course patients have never had someone spend as much time as you, but that's because there's internal conflict in you and you seem to want to please the patient to your own detriment. If your colleague down the door decided to spend one hour with the patients, the patients would say that person was the best doctor, not you. But that wouldn't be accurate either. You really need to set boundaries because your current way of doing things is not sustainable.

I think what troubles me most about your situation is that based on what you're saying, there seems to be an overabundance of follow up patients who cause you stress/are complicated which isn't the norm. So either you're stressed by what would ordinarily be considered routine follow up or your patient population is too acute for outpatient care and I can't figure out which.

 

[hallowmann]

I've been told my base of knowledge is good, and I've always done well on tests, including in psychiatry specifically. But I find it stressful that I know what is textbook-right but the real world doesn't work like that, and the things I know to be textbook-right are hard to implement.

This also ties into what I consider a stressful encounter. Basically, it's when I tell patients what I think should happen, and they refuse. Or when they disagree with the diagnosis or are in denial. Or when patients are chronically doing high-risk things and refuse to change or go into recommended treatment. And then I am faced with a choice. I can tell them we can't work together, or force-taper them from whatever they're on from before that I don't think is a good idea, or... Well, you know, try to find a compromise or a plan that is the lesser of the evils.

PS: Oh yeah and I worry excessively about side effects. When I try to come up with a plan, I often find myself playing mental chess with risk factors that I over-estimate, and end up boxing myself in a corner. I'm like "can't do this, can't do that, can't do this other thing, don't have enough experience with that, help me...."

So what I basically have to do is, in parallel with the conversation with the patient, I need to expend a fair bit of effort to keep my cool and a rational perspective. If they're out the door early, I need to decompress from that. Or I cope by making sure the history-taking and discussion is as thorough as it can be in the time I have. Either way, there's no time for notes. 🙁

I also get stressed when the patient's been on a lot of meds and they are running out of options. Because that means there will come a time when I have to tell them that maybe their problem can't be solved by meds... and they're likely not to like that.

tl;dr it’s conflict and risk, of which I have an over inflated sense.

This is a bit interesting. I think your difficulty with telling patients their problems won't be solved with medications is something you need to overcome. In fact, I would almost encourage you to go out of your way to bring this up. What you'll likely find is that for many patients, you'd be telling them something they already know and not necessarily something they wouldn't like. Obviously how you present this can be either in a validating way or in a way that implies hopelessness, the former obviously being better.

Our job isn't always to change medications when people are struggling. If every time a patient is in crisis or struggling they are offered a medication change it reinforces an idea that this is what they need or this is what they should expect. I wonder if your fear of liability also pushes you to offer a change more often (e.g. something like "well if they told me they have SI every time they think of X and I don't make a med change, then they hurt themselves, then that's going to be my fault").

You also need to work on what's your responsibility and what's your patient's responsibility. If you offer reasonable plans/options and they refuse, that's not necessarily your responsibility to find them a worse alternative that you're uncomfortable with. If they refuse treatment and then proceed to kill themselves a week or a month later, it's also not in your power to prevent that. We aren't mind readers or fortune tellers despite what the pop culture may depict of psychiatrists. Just explore what is preventing them from getting onboard with your plan because that may help you pitch another option or modify the plan (but you should not feel pressured to do this), document that you recommended it but they declined, and then move on.

I will honestly say that it is difficult for a connection to be made with a patient in 15 min, especially a new patient, and I am not so sure that PCPs being overburdened with seeing 30+ patients a day is a great example of this. That said, @Mass Effect is on point with the statement that spending more time with a patient or being more liked doesn't necessarily mean you are providing better care. You'll have to tease out whether the difference between 25 min and 30 min really makes/made a meaningful impact for the patient. With some situations and people, it absolutely may make a difference, with most others it will not. In many cases it wouldn't make a difference even if you spent an extra 15-30 min with them.

I think you can overcome a lot of these obstacles, but it really will take internalizing some of this and obviously continuing to work with a therapist that fits what you need.

 

[meow1985]

OP, it's interesting that you mention struggling with patients who have a reason why any suggestion you make is not going to work.


What do you think is happening in this conversation?

You're suggesting that I have countertransference toward my patients because I see a bit of myself in them? You're correct.

I find my own self to be stressful to be around, too, for the record. 🙂

 

[meow1985]

This is a bit interesting. I think your difficulty with telling patients their problems won't be solved with medications is something you need to overcome. In fact, I would almost encourage you to go out of your way to bring this up. What you'll likely find is that for many patients, you'd be telling them something they already know and not necessarily something they wouldn't like. Obviously how you present this can be either in a validating way or in a way that implies hopelessness, the former obviously being better.

Our job isn't always to change medications when people are struggling. If every time a patient is in crisis or struggling they are offered a medication change it reinforces an idea that this is what they need or this is what they should expect. I wonder if your fear of liability also pushes you to offer a change more often (e.g. something like "well if they told me they have SI every time they think of X and I don't make a med change, then they hurt themselves, then that's going to be my fault").

You also need to work on what's your responsibility and what's your patient's responsibility. If you offer reasonable plans/options and they refuse, that's not necessarily your responsibility to find them a worse alternative that you're uncomfortable with. If they refuse treatment and then proceed to kill themselves a week or a month later, it's also not in your power to prevent that. We aren't mind readers or fortune tellers despite what the pop culture may depict of psychiatrists. Just explore what is preventing them from getting onboard with your plan because that may help you pitch another option or modify the plan (but you should not feel pressured to do this), document that you recommended it but they declined, and then move on.

I will honestly say that it is difficult for a connection to be made with a patient in 15 min, especially a new patient, and I am not so sure that PCPs being overburdened with seeing 30+ patients a day is a great example of this. That said, @Mass Effect is on point with the statement that spending more time with a patient or being more liked doesn't necessarily mean you are providing better care. You'll have to tease out whether the difference between 25 min and 30 min really makes/made a meaningful impact for the patient. With some situations and people, it absolutely may make a difference, with most others it will not. In many cases it wouldn't make a difference even if you spent an extra 15-30 min with them.

I think you can overcome a lot of these obstacles, but it really will take internalizing some of this and obviously continuing to work with a therapist that fits what you need.

You're correct that I want to please patients, but that's partly because they are evaluating me. All employed physicians get patient survey results, and that is part of their performance review, which directly relates to their future at that job. Also, someone (coughPamelaWiblecough) once said that patients do not sue doctors they like, and while that may or may not be empirically supported, that stuck with me. The unfortunate situation is that you're caught between a rock and a hard place - you want to be liked by patients, but sometimes you're doing to *have to* do and say things patients won't like because that's what's best for them. *That* is stressful.

I do try to be mindful to not change meds whenever there's a symptom, and I do a decent amount of therapizing and giving non-pharmacological advice in my sessions. That may be a part of the issue -- I have a low threshold for jumping into therapy mode, but therapy is meant to be done in hour-long sessions, not 30 minutes when your focus is meant to be more medical!

I've had it all go all kinds of ways when I told patients the solution to their problem lies outside of medications. Some took it well, some gave me pushback or accused me of not helping them. Rolling with that pushback is stressful, and so is not knowing ahead of time how it's going to go. I've been known to be anxious about an upcoming patient encounter for *days in advance* when I know I have to have a tough discussion with someone.

I think what troubles me most about your situation is that based on what you're saying, there seems to be an overabundance of follow up patients who cause you stress/are complicated which isn't the norm. So either you're stressed by what would ordinarily be considered routine follow up or your patient population is too acute for outpatient care and I can't figure out which.

At my prior job, the population was very acute, lots of post-hospital discharges, lots of substance abuse without adequate resources, lots of lower-functioning patients, drug-seekers, and generally people whose bio, psycho, and social elements were a constant dumpster fire.

At my current job, I am new so the jury is still out. I came here specifically because it was described as a more "suburban middle class" population. But here I've still had my share of hospital discharges, substance abuse patients, and elderly people on long-term benzos who refuse to give them up. I've discovered cognitive impairment is another realm to worry about - how are they functioning at home? Am I missing a burgeoning dementia? Should they be driving? There are so many meds that are high risk for them!

So I guess it's a little bit of both of your hypotheses. Overall, I get more stressed by confrontation and (real or imagined) risk than other people. So I *need* a less acute population, but that doesn't solve the whole problem.

 

[Bartelby]

Two thoughts:

1- I seriously doubt they will fire you for bad patient feedback unless it reaches a seriously bad place. Occasional unhappy patients will not get you fired, and good practice will inevitably involve this.

2- Being liked by patients helps, but patients do sue doctors they like for a variety of reasons, not least of which can be feeling they need the money to survive after a bad incident. I strongly believe good rapport is important to improving outcomes and making practice all around more pleasant, but it's good to right-size these considerations. Often when patients don't like a doctor for not taking the time (in my experience) it has been more egregious, like taking months for follow-up when weeks would have been appropriate, or spending just a few minutes with a dismissive attitude.

It's good you have a lot of insight into all of this though! It sounds to me like you are in a place to continue working on issues and making the best of your practice. And by the way, I think all of us struggle with this kind of stuff to greater or lesser extents from time to time.

 

[calvnandhobbs68]

I said if things are more complicated or more high risk, 30 minutes is barely enough.

If things are low-to-medium complicated and the patient isn't the biggest talker in the world, I can even do 20 minutes or less. But right now that situation is not common in my practice.

But if it's one of the one who can't stop talking, or if there's a crisis or other WTF situation, or they're super anxious about side effects or find a problem with every suggestion, then yeah, I run up against that 30 minute timeframe. In fact, in WTF situation my defense mechanism is to start gathering more information in hopes that it will make me feel better about whatever solution I provide. I need not not do that, maybe.

Low complicated should be like 5 minutes. Low complexity is like “yeah doc the SSRI is working great, jobs good, my sleep is fine, appetite is good, mood is fine no problem”. PCPs literally rip through low complexity patients in 5-10 min total. Your documentation can also be like 3 lines for low complexity (99213) patients and still meet billing requirements.

Go check out a derm or GI note for a great example of this. “Followup GERD, previously normal EGD, reflux sx stable on omeprezole 20mg daily, no new red flag sx” is like literally a subjective progress note section.

 

[meow1985]

Low complicated should be like 5 minutes. Low complexity is like “yeah doc the SSRI is working great, jobs good, my sleep is fine, appetite is good, mood is fine no problem”. PCPs literally rip through low complexity patients in 5-10 min total. Your documentation can also be like 3 lines for low complexity (99213) patients and still meet billing requirements.

Go check out a derm or GI note for a great example of this. “Followup GERD, previously normal EGD, reflux sx stable on omeprezole 20mg daily, no new red flag sx” is like literally a subjective progress note section.

That's ultra-low complexity. If someone is *just* on an SSRI and doing well, they're generally being taken care of by their PCP's, not me, and yes, 10 minutes is enough for that.

 

[SeniorWrangler]

Honestly, if you're making enough money to meet your goals, I think your next priority should be to prevent burnout. Once you get burned out, it's a long slog to get yourself sorted out again and it's an invisible struggle. I personally have found "senior psychiatrists" to be the opposite of helpful, even when they're well-meaning, they're just coming from a different place and can't give helpful advice. Your experience may vary.

 

[clausewitz2]

That's ultra-low complexity. If someone is *just* on an SSRI and doing well, they're generally being taken care of by their PCP's, not me, and yes, 10 minutes is enough for that.

Could you give us an idea of what in your estimation a "low-complexity" sort of patient is?

You'd be surprised how many PCPs stop feeling comfortable with, say, Zoloft at any dose above 50.

 

[calvnandhobbs68]

Could you give us an idea of what in your estimation a "low-complexity" sort of patient is?

You'd be surprised how many PCPs stop feeling comfortable with, say, Zoloft at any dose above 50.

Yeah I swear a significant proportion of my intakes are like Prozac 20mg didn’t work….refer to psych.

 

[meow1985]

Yeah I swear a significant proportion of my intakes are like Prozac 20mg didn’t work….refer to psych.

An example low complexity patient is a pleasant, not excessively chatty person with several-to-multiple past med trials where we eventually did find something that works, but they've developed a side effect of initial insomnia, so we have to discuss relaxation techniques and enhancing sleep hygiene vs a sleep med vs yet another change of the primary med. Also now that their primary issue is under better control the want to work on quitting smoking or getting assessed for ADHD or something.

My institution has a shortage of psychiatrists and several who have left recently so PCP's had to manage a lot of things (idk what it is, psychiatrists at both places I've worked so far have seen covid as an opportunity to peace out).

 

[calvnandhobbs68]

An example low complexity patient is a pleasant, not excessively chatty person with several-to-multiple past med trials where we eventually did find something that works, but they've developed a side effect of initial insomnia, so we have to discuss relaxation techniques and enhancing sleep hygiene vs a sleep med vs yet another change of the primary med. Also now that their primary issue is under better control the want to work on quitting smoking or getting assessed for ADHD or something.

My institution has a shortage of psychiatrists and several who have left recently so PCP's had to manage a lot of things (idk what it is, psychiatrists at both places I've worked so far have seen covid as an opportunity to peace out).

Coool so that’s either a not talk too much about insomnia kind of issue, a here’s doxepin 10mg QHS let’s followup on the insomnia in a few weeks kind of issue or at a bare minimum a 99213 + 90833 if not a 99214 + 90833 if your spending that much time talking about sleep hygiene and relaxation techniques.

I mean that’s why it’s worth it to get paid based on productivity because at least there’s an incentive to sit around talking to people about their insomnia they can’t figure out by themselves for another 15-20min so they take up your whole half hour.

 

[Mass Effect]

An example low complexity patient is a pleasant, not excessively chatty person

Being chatty has nothing to do with complexity and everything to do with boundaries that you're supposed to set (unless they're manic).

 

[meow1985]

Being chatty has nothing to do with complexity and everything to do with boundaries that you're supposed to set (unless they're manic).

It takes effort to keep redirecting and interrupting big talkers — most of my patients who are like that are the elderly or the anxious. So for me that adds to the stress of the encounter, even if it isn’t directly reflected in medical decision making.

 

[calvnandhobbs68]

It takes effort to keep redirecting and interrupting big talkers — most of my patients who are like that are the elderly or the anxious. So for me that adds to the stress of the encounter, even if it isn’t directly reflected in medical decision making.

Is there anything that doesn’t make you anxious….

Maybe try to identify that first and then you’ll find your ideal job.

 

[meow1985]

Is there anything that doesn’t make you anxious….

Not having responsibility.

But I kind of need money.

 

[Monocles]

Not having responsibility.

But I kind of need money.

OP have you considered prior auth review? It's probably not the money you are making as an attending seeing patients clinically, but it allows you to work generally at your own pace, and without having to put up with challenging or difficult patients directly.

 

[meow1985]

OP have you considered prior auth review? It's probably not the money you are making as an attending seeing patients clinically, but it allows you to work generally at your own pace, and without having to put up with challenging or difficult patients directly.

I wouldn't mind it. I could even do "consulting" whatever that is. Not sure how to break into those types of roles, but I suppose I can research it.

 

[meow1985]

Thing is, though, when a patient and I are able to build a trusting dynamic, I'm able to make a difference for them (through meds or just teaching them something new about themselves and their life) it really, really, really is rewarding. And if there could be a guarantee that I would never get sued again and never lose my job and if something went wrong a heartfelt apology would be enough (because negligent is not something I am capable of being), then I would love my job and practice without fear. But that's not the world we live in.

 

[VA Hopeful Dr]

Isn't psychiatry the least sued specialty by a large margin?

 

[calvnandhobbs68]

Isn't psychiatry the least sued specialty by a large margin?

Yes

psychiatrists are an extremely anxious bunch about getting sued in general for no apparent reason besides worrying that their patients are going to commit suicide generally (which in and of itself is a pretty statistically rare event). I’ve commented on this before but I did another (higher risk) specialty before psychiatry and we never talked about defensive documentation as much as in psychiatry.

 

[Mad Jack]

I read Bessel van der Kolk's "The Body Keeps the Score," and I've realized that I have trauma reactions about my job all the time.

My state is a disconnect between the role I play, that of the confident, calm, self-assured specialist who can keep their head in a crisis and come up with a solution, and the person that I am, who feels constantly in danger and ill-equipped to do much of anything. Not physical danger per se, but professional and emotional danger. In physical danger, I know what to do, just get the heck out and call security. Emotional and professional danger is more complicated. Patients angry at you, patients complaining, or simply going into a situation and not being able to come up with a plan, or bungling things under pressure. A bad outcome resulting in an institutional investigation, a board investigation, a lawsuit, or simply colleagues' censure. That kind of danger. In the end everything usually works out and I am able to come up with some reasonable intervention, but somehow that doesn't "teach" me that yes, I am capable, and yes, everything will probably be alright.

I changed to a job with a slightly more stable, worried well population, but suicidal, homicidal, substance abusing, and capacity-lacking patients are everywhere. I feel unsafe when I know I am responsible for their violent and self-harming behaviors, yet am ill-equipped to mitigate the risk.

Switching jobs helped, since now at least my staff doesn't give me pushback when I ask them to do something.

I spend my days off self soothing myself back to a state where I'm ready to face it all again. Working less is not a solution because I just worry about all the fires I'm not there to put out - though, again, with more reliable coverage and support staff at new job this has improved a bit.

My therapist is unhelpful. He is an older private practice MD who does mostly therapy. I thought he'd be able to understand what I am going through, and he does, but all he does by way of counsel is pontificate about his fringey views and how jaded modern psychiatry makes him. I tried giving him feedback, but that hasn't helped. I might need to find a different therapist.

Idk what to do. Looking for perspective or guidance, I guess.

It sounds like you really need to find a sense of acceptance in the fact that there are some things you just can't control. People die. People relapse. People self-harm. People will be demanding and irritable and dislike you. The most dangerous view you can hold is that you can stop all of this if only you try hard enough. All you can do is to try your best and take solace in a job well done- you are giving patients the best shot they have, but sometimes even that won't be enough. Because of the nature of our connection with patients, the losses feel much more personal, but we are no different than cardiologists, pulmonologists, oncologists, or any ither physician in the sense that outcomes are not always going to fall in our favor. All we can do is try our best and hopefully make a positive difference along the way

 

[Monocles]

I wouldn't mind it. I could even do "consulting" whatever that is. Not sure how to break into those types of roles, but I suppose I can research it.

Look into Optum and Blue Cross Blue Shield - oftentimes they are in need of case reviewers. Rates I believe are in the $100-125 per hour range.

(I am not board certified, otherwise I would totally do this as a side hustle)

 

[clausewitz2]

Yes

psychiatrists are an extremely anxious bunch about getting sued in general for no apparent reason besides worrying that their patients are going to commit suicide generally (which in and of itself is a pretty statistically rare event). I’ve commented on this before but I did another (higher risk) specialty before psychiatry and we never talked about defensive documentation as much as in psychiatry.

One of my ED psychiatry attendings once pointed out to me that we could just discharge literally everyone who walked in the door without even talking to them and it probably wouldn't make a statistically significant difference in the local completed suicide rate because it is such a low frequency event. Suicide attempts/suicidal gestures, on the other hand...

We get emotionally involved with patients in a way that other specialties don't much of the time. It's hard to talk to someone about emotional things for a good chunk of time on a regular basis and not get invested. As others have said in this thread, though, that investment just means it's harder to accept bad outcomes will happen, not that they won't.

 

[clausewitz2]

Look into Optum and Blue Cross Blue Shield - oftentimes they are in need of case reviewers. Rates I believe are in the $100-125 per hour range.

(I am not board certified, otherwise I would totally do this as a side hustle)

Some companies will take you if you are board-eligible. One thing I will say is that the volume can be somewhat unpredictable, and some companies will specify how much time they believe reviewing the case should take you and put up roadblocks to getting more time approved.