Occupational trauma

[Monocles]

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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.

Ooh this is good to know!

But yeah, apparently a friend of a friend does 8 cases a day... from his fishing boat lmao.

 

[Stagg737]

4) Clicking all the things in Epic.

If you're using Epic you should take a few days to just create .phrases for everything you can think of. You type 5 letters and BOOM, your paragraph is there. Something new comes up that seems common(ish)? Take 15 minutes after work to make a new .phrase. It'll literally save you hours or even days of work down the road.

This was the best decision I made in residency in terms of documentation and literally cut my work time in half once I had them all finished.

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.

I had an attending whose entire follow-up note was "Patient seen for f/up. Reports stability on medications. Denies SI/HI/AVH. Continue meds." with a bunch of auto-populated info and he is yet to be fired after 10+ years of that.

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).

The underlined should realistically not take more than 5 minutes. Ask them which of the three they prefer, then lay out their options. Go over sleep hygiene basics, but provide resources they can follow. My favorite piece of advice that I've gotten (which I regularly remind myself) is that you shouldn't be doing more work than your patient. If they can't put a basic effort in, nothing you do is going to make a difference and you're exhausting yourself for no reason.

Imo the bolded automatically ups this into moderate complexity. Most PCPs I've had won't even talk about other issues I'm experiencing and will tell me to make another appointment. This is certainly low acuity, but the number of things you're addressing and info you're providing doing all of the above is not a simple encounter.

 

[Mad Jack]

If you're using Epic you should take a few days to just create .phrases for everything you can think of. You type 5 letters and BOOM, your paragraph is there. Something new comes up that seems common(ish)? Take 15 minutes after work to make a new .phrase. It'll literally save you hours or even days of work down the road.

This was the best decision I made in residency in terms of documentation and literally cut my work time in half once I had them all finished.



I had an attending whose entire follow-up note was "Patient seen for f/up. Reports stability on medications. Denies SI/HI/AVH. Continue meds." with a bunch of auto-populated info and he is yet to be fired after 10+ years of that.




The underlined should realistically not take more than 5 minutes. Ask them which of the three they prefer, then lay out their options. Go over sleep hygiene basics, but provide resources they can follow. My favorite piece of advice that I've gotten (which I regularly remind myself) is that you shouldn't be doing more work than your patient. If they can't put a basic effort in, nothing you do is going to make a difference and you're exhausting yourself for no reason.

Imo the bolded automatically ups this into moderate complexity. Most PCPs I've had won't even talk about other issues I'm experiencing and will tell me to make another appointment. This is certainly low acuity, but the number of things you're addressing and info you're providing doing all of the above is not a simple encounter.

The problem with Epic is that some builds have a lot of checkboxes that can only be filled in pop-out frames, drastically slowing you down. Often these are due to hospital tracking metrics and there is no way to autofill them that will also make them trackable. I've seen a place where an admission on Epic takes 2 minutes and one where it takes an hour, with the latter all due to various screens and checkboxes (this is before your note, and the notes themselves at the latter location were also quite demanding)

 

[calvnandhobbs68]

The problem with Epic is that some builds have a lot of checkboxes that can only be filled in pop-out frames, drastically slowing you down. Often these are due to hospital tracking metrics and there is no way to autofill them that will also make them trackable. I've seen a place where an admission on Epic takes 2 minutes and one where it takes an hour, with the latter all due to various screens and checkboxes (this is before your note, and the notes themselves at the latter location were also quite demanding)

Right Epic has good and bad things about it...the ability to customize builds is touted as a good thing until you realize your build is dictated by your asshat administrators who only care about if you checked a box saying you counseled the patient on smoking cessation every visit or some dumb **** and then make 100 checkboxes you have to decide whether to check or not.

Also my personal rant but checkboxes are 10x more infuriating on a computer than on a piece of paper or just copying and pasting/dotphrasing blurbs...but they're way easier to track for the bean counters rather than going through notes.

 

[Stagg737]

The problem with Epic is that some builds have a lot of checkboxes that can only be filled in pop-out frames, drastically slowing you down. Often these are due to hospital tracking metrics and there is no way to autofill them that will also make them trackable. I've seen a place where an admission on Epic takes 2 minutes and one where it takes an hour, with the latter all due to various screens and checkboxes (this is before your note, and the notes themselves at the latter location were also quite demanding)

Right, but for what OP is describing dot phrases are ideal. We don’t need to write a paragraph to justify prescribing one med except for rare cases. If OP feels it’s necessary, fine, but this is The perfect example of how to use dot phrases to make our lives so much easier.

 

[Candidate2017]

Right Epic has good and bad things about it...the ability to customize builds is touted as a good thing until you realize your build is dictated by your asshat administrators who only care about if you checked a box saying you counseled the patient on smoking cessation every visit or some dumb **** and then make 100 checkboxes you have to decide whether to check or not.

Also my personal rant but checkboxes are 10x more infuriating on a computer than on a piece of paper or just copying and pasting/dotphrasing blurbs...but they're way easier to track for the bean counters rather than going through notes.

Make a dot phrase that covers the language of the 100 checkboxes. It takes a long time for admin to figure out you're not checking the boxes. When they finally ask why you aren't checking the 100 boxes, point to your notes and offer them your dot phrase to implement as an efficiency/error reduction/patient satisfaction mechanism.

 

[Fuzzy08]

OP, Im literally in the same boat as you with anxiety and overthinking. Whats been helpful so far is knowing that many psychiatrists/midlevels half ass their work and write subpar notes and pretty much all of them are still in practice and getting paid. Just don't sleep with your patients and you'll be fine.

 

[untapped]

OP, Im literally in the same boat as you with anxiety and overthinking. Whats been helpful so far is knowing that many psychiatrists/midlevels half ass their work and write subpar notes and pretty much all of them are still in practice and getting paid. Just don't sleep with your patients and you'll be fine.

I felt inadequate until I rotated with a psychiatrist in the community at a rural hospital. This guy has kept his job despite ignoring or being ignorant to all standards of care post 1990.

 

[calvnandhobbs68]

I felt inadequate until I rotated with a psychiatrist in the community at a rural hospital. This guy has kept his job despite ignoring or being ignorant to all standards of care post 1990.

Yep.
This is always helpful to reorient yourself to just how low the standard of care is (in many different specialties).
If you’re even wondering if you’re inadequate you’re probably doing better than a decent chunk.

 

[clausewitz2]

Yep.
This is always helpful to reorient yourself to just how low the standard of care is (in many different specialties).
If you’re even wondering if you’re inadequate you’re probably doing better than a decent chunk.

This reminds me of someone I knew who was a long-time dual diagnosis therapist who told me their trick for coping with a really bad day. They'd always tell themselves "well, I don't have a needle in my arm, so I'm doing okay." Holding yourself to high standards is great but also important to recognize that good enough care is better than a significant chunk of the care they might receive elsewhere.

 

[robellis]

I felt inadequate until I rotated with a psychiatrist in the community at a rural hospital. This guy has kept his job despite ignoring or being ignorant to all standards of care post 1990.

Can you give specific examples as to this guys practice?