Outpatient Employer Expectations

[Fabio001]

Hi all. For those working outpatient in an employed position, have there been any employer expectations that were surprising? More specifically, were there expectations as far as being physically in the building during work hours or needing to get approval for longer appointments? Anything else unexpected?

During my residency, the expectation for outpatient clinic was that I'm there for supervision and for any scheduled patient appointments (obviously), but otherwise I was free to take a long lunch break if my first afternoon patient cancelled, or was good leave early if my last appointment spot of the day didn't fill, etc... I assumed this was the norm. However, when I started my first attending job, an outpatient community position in a different area of the country, I was surprised by the expectation that I'm on-site during work hours, regardless of whether patients are scheduled. This wasn't explicitly stated in my interview, but apparently it was implied by them informing it was a full-time position with the expectation of 40 hours/week. Needless to say, when we returned to in-person services last summer, I was a bit blindsided, and it's been an ongoing source of contention. Is this consistent with the experience of others? Very interested in any thoughts or experiences. Thanks!

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[randomdoc1]

As an employer and an outpatient psychiatrist, I always say, it's never a bad idea to ask specific questions (e.g. such as when you were expected to be on site during work hours). I'm assuming the reason they have that expectation is in case matters come up such as same day patient appointments, urgent messages and other matters you can bill for and generate revenue for the clinic for. Is there any reason you cannot continue to generate revenue off site? For example, maybe certain insurances are no longer reimbursing for telehealth from patient being at home? Because if you are still able to get billable productivity done, your employer might still be happy about that. Although, as an employer, I think they also should have held their end of the communication by being specific as possible about matters like that. When I worked at the VA, I stayed on site whether I had patients scheduled or not during the tour. I just assumed a 0.5 FTE was a 0.5 FTE and many vets preferred to come in person or sometimes staff would stop by my office.

I suppose it also depends on what you and your employer are looking to get out of the relationship. Most employers like to keep the psychiatrist full and busy because well....it means more money for them too. It applies both for if you are salaried or on a production model. Even the VA tracks your productivity. Which I can understand as well, because the money to at least meet the salary, has to come from somewhere and if the incentive is so low to see patients, the clinic would be at a net loss which is unsustainable. For your question about longer appointments, I've seen most employers be ok with that as long as it is discussed in advance and some employers are more strict than others about asking the provider accurately bill the time. For example, if you had a 45 min visit, they want to see you bill a 99213/99214 with 90836 (not 90833).

I've boarded on some newly graduated providers. Some of them were a bit surprised with attending life when they realized if they wanted to make x income, they needed to have x visits. One provider was working at a 0.6 FTE and was wondering why she was not getting 1.0FTE pay. I broke down the RVUs for her and we discussed other employment models and it started to sink in. At least in my residency, our clinic days were nowhere near as busy as that of an attending. And I too was a bit surprised after graduation at how many patients a 1.0 FTE say, at the VA, had to see.

 

[surfguy84]

As an employer and an outpatient psychiatrist, I always say, it's never a bad idea to ask specific questions (e.g. such as when you were expected to be on site during work hours). I'm assuming the reason they have that expectation is in case matters come up such as same day patient appointments, urgent messages and other matters you can bill for and generate revenue for the clinic for. Is there any reason you cannot continue to generate revenue off site? For example, maybe certain insurances are no longer reimbursing for telehealth from patient being at home? Because if you are still able to get billable productivity done, your employer might still be happy about that. Although, as an employer, I think they also should have held their end of the communication by being specific as possible about matters like that. When I worked at the VA, I stayed on site whether I had patients scheduled or not during the tour. I just assumed a 0.5 FTE was a 0.5 FTE and many vets preferred to come in person or sometimes staff would stop by my office.

I suppose it also depends on what you and your employer are looking to get out of the relationship. Most employers like to keep the psychiatrist full and busy because well....it means more money for them too. It applies both for if you are salaried or on a production model. Even the VA tracks your productivity. Which I can understand as well, because the money to at least meet the salary, has to come from somewhere and if the incentive is so low to see patients, the clinic would be at a net loss which is unsustainable. For your question about longer appointments, I've seen most employers be ok with that as long as it is discussed in advance and some employers are more strict than others about asking the provider accurately bill the time. For example, if you had a 45 min visit, they want to see you bill a 99213/99214 with 90836 (not 90833).

I've boarded on some newly graduated providers. Some of them were a bit surprised with attending life when they realized if they wanted to make x income, they needed to have x visits. One provider was working at a 0.6 FTE and was wondering why she was not getting 1.0FTE pay. I broke down the RVUs for her and we discussed other employment models and it started to sink in. At least in my residency, our clinic days were nowhere near as busy as that of an attending. And I too was a bit surprised after graduation at how many patients a 1.0 FTE say, at the VA, had to see.

What were your busiest residency days like?

 

[randomdoc1]

What were your busiest residency days like?

For outpatient is was in the territory of 8 patients a day? I thought that was pretty light in comparison to an attending. Then again, it depends on how much you're looking to make as an attending. At this point in the career, if I didn't have a practice to manage and just did regular psychiatry, assuming good collections and insurance rates, the reimbursement of 8 patients a day or 40 a week would be pretty comfortable imho but every psychiatrist has their own preference on how much they're aiming to get.

 

[Sushirolls]

If there is no logistical reason to be on site. Let them know its an issue, and you'll manage your time as you see fit. If the don't like it, resign, and go find a better job.

My first job as new graduate I still had that residency mind set. I had to be there, for the full time. My colleagues took advantage of that, and would skip off to their outpatient clinic, and while I finished up my inpatient notes or did family meetings, I some how found myself covering for their inpatients too. Or doing extra consults because I was still in the hospital. I choose to not do as much / reduce my outpatient clinics on inpatient days to preserve my clinical quality.

You are a professional, and physician. If there isn't a job obligation of walk in acute patients needing to be seen for this outpatient clinic, or some TMS obligation of being onsite while treatments take place, then you should be able to leave. There should be no guilt in this. Job wants you to stay on site like a shift worker, then find a new job if it irks you that much. Personally, I do SDN, or take a nap, or catch up on notes, or CME, etc. But if have a personal thing worthwhile, I'll dart, now that I'm over that fresh graduate mentality - there isn't any reason for you to be there.

 

[comp1]

Yeah, the VA is going to expect you to be on site during your tour and I imagine a lot of other places will too. The idea is to have a physician available to handle emergencies or urgencies, even if they aren't your personal scheduled patients. They're not micromanaging your day, but they do need you physically available if something like that occurs. If you're REGULARLY not having patients during a given time in your tour, there may be be something wrong with your scheduling grid.

 

[TexasPhysician]

This is something to discuss and have in writing prior to starting a job. This is 1 reason that I have an attorney help with all contracts.

As an employee, you are subject to the rules of the employer or your contract. There is 0 professional expectation that you can be away when not scheduled. Whether we believe we have earned it or not, it isn’t a legal thing, which is all that matters.

I’ve walked away from reasonable jobs over certain requirements.

 

[calvnandhobbs68]

I don't think OP is at the VA.

OP you're child right? And didn't you have like 2 hours of "admin" time a day or something? yeah I don't get why you need to be there for admin time either.

You should try to be upfront with them about this if this is really a make or break thing for you. But if i remember right this is that job that paid 295K with basically a 2.5 hour break every day and entire day of supervision....which is a pretty solid deal to begin with so they might start cutting your admin time or something. However, also recognize you're C+A and they'll have a hard time replacing you in general, so you might have a bit more leverage here.

 

[ObsequiousAplomb]

What were your busiest residency days like?

Typical days in my main clinic for PGY-3 outpatient for me were 12 patients: 2 psychotherapy, 2 new, and 8 follow-ups. Hours were 9:20-5 with a one hour lunch. Psychotherapy or intakes were 60 minutes, follow-ups were 20 minutes.

10% no-show rate for the 20 minute appointments, 1% no-show rate for the psychotherapies, and 36% no-show rate for intakes. So the busy days were the days both intakes showed up.

 

[RevDO]

I've boarded on some newly graduated providers. Some of them were a bit surprised with attending life when they realized if they wanted to make x income, they needed to have x visits. One provider was working at a 0.6 FTE and was wondering why she was not getting 1.0FTE pay. I broke down the RVUs for her and we discussed other employment models and it started to sink in. At least in my residency, our clinic days were nowhere near as busy as that of an attending. And I too was a bit surprised after graduation at how many patients a 1.0 FTE say, at the VA, had to see.

Is it reasonable to make $350k outside of NY/CA? What would a day of somebody doing this look like?

 

[calvnandhobbs68]

Is it reasonable to make $350k outside of NY/CA? What would a day of somebody doing this look like?

This has nothing to do with OPs question and you've had responses to things like this in other threads (including ones you've posted in or started). Shall I refer you back to:

Salary Question

Hello, I am wondering if it is reasonable to make $300k+ in psych working around 40 hours/week. People I've talked to say you can make "a lot" in psych but have been hesitant to discuss actual numbers. I don't mind working hard and want to provide good care for my patients but I also want to be...

forums.studentdoctor.net

 

[trophyhusband]

I'd say this is pretty standard based on my wife and her friends experiences. If you're getting a salary they generally expect you to be on-site. Now if you're being paid on a wRVU basis you have an argument that if there are no patients you're not generating wRVU's so there's no point in you being there.

This is one of the reasons my wife went into PP. When there's no patients she's not there... but she's also not generating revenue. There's safety in salary but then you're not in control of your time (the person who cuts the check is).

 

[smalltownpsych]

As someone who runs an outpatient practice, my expectation of the psychiatric nurse is to be there when there are appointments and know which days and times they are available for appointment. I would have the same expectation for a psychiatrist. This is also not a salaried position so if it was then the expectation could be a little different. It is hard for me to see why outpatient would be salaried though. I do wonder a bit about phone calls regarding prescription problems and what the expectations should be and how to handle those best. When it comes to mental health crises such as suicidality, I feel comfortable and have experience with managing those with whatever resources are available to me at the moment and the phone is off outside of business hours.

 

[randomdoc1]

As someone who runs an outpatient practice, my expectation of the psychiatric nurse is to be there when there are appointments and know which days and times they are available for appointment. I would have the same expectation for a psychiatrist. This is also not a salaried position so if it was then the expectation could be a little different. It is hard for me to see why outpatient would be salaried though. I do wonder a bit about phone calls regarding prescription problems and what the expectations should be and how to handle those best. When it comes to mental health crises such as suicidality, I feel comfortable and have experience with managing those with whatever resources are available to me at the moment and the phone is off outside of business hours.

I can imagine the prescription calls can be an area of discussion especially if the employer is not a prescriber. How we have it set up here is clinical questions are triaged to the prescriber. If it sounds like it could be of medical urgency, it would be good to discuss a triage plan with the prescriber. Usually the prescriber can call the patient back or provide an appointment in the near future. But if things are too booked, referring to a place like urgent care would be an option too. Emergencies be it medical or behavioral health, we tell patients to report to the local ER and if behavioral health, we have psych ERs nearby.

As a prescriber, prescription calls sometimes can get annoying. Especially if it takes up more time you are not getting paid for. So usually when it's a clinical question I try to just get the patient scheduled (e.g. there's a cancellation that opened up that day) so the provider can get paid for their time. Unless of course the clinical question is super straight forward (e.g. to clarify a dose that was already written in the medical record).

There's another breed of prescription calls that drives me and every psychiatrist I know crazy. And I personally feel it should not be the prescriber's job to handle these. Pharmacies or patients call saying they need a refill when they already have an order at the pharmacy. At our office, we check the order history first and have the front desk call the pharmacy, tell them the fill the damn script they already have on file, then call the patient back and let them know the pharmacy was being stupid and they are working on filling the script for them. If there truly is no order on file and a refill order is needed, then yes, I send the message to the prescriber. But we easily get 5-10 calls a day for "refills". One way to greatly cut down on these calls is with each medication order, even if the patient is already established on it, I put in the comments to "discontinue any pre-existing scripts for this medication." That way pharmacies don't get hung up on an old order and the new order is the only active one on file (cuts down the bs by about 90%, unfortunately there's still a proportion that don't read the whole order).

Is it reasonable to make $350k outside of NY/CA? What would a day of somebody doing this look like?

By my calculation, if someone works at 48 weeks a year, 6h days so 12 follow ups, makes it 60 follow ups a week. Insurance reimbursement is in the territory of $170-$175 per half hour (99213 with 90833 puts it around $150s and a level 4 with psychotherapy puts it near $200 a follow up). We do get some no shows but most people pay their fees. Puts things at around $391680?

 

[hamstergang]

There's another breed of prescription calls that drives me and every psychiatrist I know crazy. And I personally feel it should not be the prescriber's job to handle these. Pharmacies or patients call saying they need a refill when they already have an order at the pharmacy. At our office, we check the order history first and have the front desk call the pharmacy, tell them the fill the damn script they already have on file, then call the patient back and let them know the pharmacy was being stupid and they are working on filling the script for them. If there truly is no order on file and a refill order is needed, then yes, I send the message to the prescriber. But we easily get 5-10 calls a day for "refills". One way to greatly cut down on these calls is with each medication order, even if the patient is already established on it, I put in the comments to "discontinue any pre-existing scripts for this medication." That way pharmacies don't get hung up on an old order and the new order is the only active one on file (cuts down the bs by about 90%, unfortunately there's still a proportion that don't read the whole order).

I'll have to try this as you're right, these are some of the most frustrating refill calls that waste so much time. They no longer waste my time personally as I've taught my front desk staff what to do, but their time is still worth something too.

 

[deleted1100659]

You're in a community clinic? I have admin time built into my schedule from 4-5 where the understanding is I dont see patients during that hour, but im available by phone if needed. Otherwise im on site, because things tend to arise throughout the day. Do you have admin time?

 

[Fabio001]

Yes, it's a community clinic. I have 2 hours of admin time per day and a 30 minute gap at lunch, and the expectation is that I'm on-site all hours 10 hours/day that I work, regardless of admin time. What made this so painful is that for the first year of my employment, I had many consecutive unscheduled hours of time due to school referrals drying up.

 

[deleted1100659]

Yes, it's a community clinic. I have 2 hours of admin time per day and a 30 minute gap at lunch, and the expectation is that I'm on-site all hours 10 hours/day that I work, regardless of admin time. What made this so painful is that for the first year of my employment, I had many consecutive unscheduled hours of time due to school referrals drying up.

My theory is that if its community health then they're probably not too great at retaining physicians, giving you some extra bargaining power. I would hammer this out in my contract or seek other employment if it was a dealbreaker. A lot of times these people act tough, but they know you're not easily replaced.

I also suggest mastering a strong resting bitch face, as ive perfected the male version which can be useful when admin trys to ask unrealistic things of me.

 

[Merovinge]

Yes, it's a community clinic. I have 2 hours of admin time per day and a 30 minute gap at lunch, and the expectation is that I'm on-site all hours 10 hours/day that I work, regardless of admin time. What made this so painful is that for the first year of my employment, I had many consecutive unscheduled hours of time due to school referrals drying up.

That seems silly to me if you are not taking walk-ins or doing anything that requires you being present. If you want to stick around I suggest using that time to do surveys, play video games, read (psychiatry or not), listen to podcasts, workout, etc.

Separately, I am shocked there is CAP clinic on earth taking insurance that has gaps. I have never encountered such a clinic. If you wanted to be busy it would be trivially easy to drum up more business.

 

[Fabio001]

We're limited to only medicaid, organizationally, which might have something to do with it. I'm a lot busier now, but there are still gaps; it's been almost 2 years and I'm still not at a full panel. I've been pretty surprised too.

 

[Merovinge]

Wow, that's an absolutely embarrassing job by administration. There's not a location in the country where patients with medicaid would not kill to get in to see a real CAP (i.e. not NP). Most medicaid patient's cant even get into see an NP who wants to work with kids.

 

[FlowRate]

There's another breed of prescription calls that drives me and every psychiatrist I know crazy. And I personally feel it should not be the prescriber's job to handle these. Pharmacies or patients call saying they need a refill when they already have an order at the pharmacy. At our office, we check the order history first and have the front desk call the pharmacy, tell them the fill the damn script they already have on file, then call the patient back and let them know the pharmacy was being stupid and they are working on filling the script for them.

All the freaking time. Patients automatically assume any issue with a prescription is my fault and not a pharmacy issue even though 95% of the time it's a pharmacy issue.

Edit: It's largely because our web portal always gives them error messages that imply it's my issue.

 

[calvnandhobbs68]

Wow, that's an absolutely embarrassing job by administration. There's not a location in the country where patients with medicaid would not kill to get in to see a real CAP (i.e. not NP). Most medicaid patient's cant even get into see an NP who wants to work with kids.

Yeah where is this mysterious place...

 

[randomdoc1]

Yeah where is this mysterious place...

the twilight zone

 

[Fabio001]

Wow, that's an absolutely embarrassing job by administration. There's not a location in the country where patients with medicaid would not kill to get in to see a real CAP (i.e. not NP). Most medicaid patient's cant even get into see an NP who wants to work with kids.

Thanks for the validation. I'm really not sure what else to say...
I've tried to be content, let sleeping dogs lie, and be productive with my downtime. The good news is that my patients who miss their appointment can usually get in with me to make it up within a day or two (and often, even that same day 🤔)

 

[splik]

Yes, it's a community clinic. I have 2 hours of admin time per day and a 30 minute gap at lunch, and the expectation is that I'm on-site all hours 10 hours/day that I work, regardless of admin time. What made this so painful is that for the first year of my employment, I had many consecutive unscheduled hours of time due to school referrals drying up.

Is this a government job? If so, the expectation is you are there the hours you are paid for work regardless of whether you have work to do. If it is not a government job you should be able to do what you like. That said, I'm not sure I would make a thing of it. I would just come and go as I please and not ask permission.

 

[Fabio001]

Is this a government job? If so, the expectation is you are there the hours you are paid for work regardless of whether you have work to do. If it is not a government job you should be able to do what you like. That said, I'm not sure I would make a thing of it. I would just come and go as I please and not ask permission.

It isn't a government job, but I joke with a colleague that it sure feels like one! Your advise is essentially what I've been doing; I suspect I'll be slapped on the wrist for it at some point, but c'est la vie.

 

[Mass Effect]

Yeah, the VA is going to expect you to be on site during your tour and I imagine a lot of other places will too. The idea is to have a physician available to handle emergencies or urgencies, even if they aren't your personal scheduled patients. They're not micromanaging your day, but they do need you physically available if something like that occurs. If you're REGULARLY not having patients during a given time in your tour, there may be be something wrong with your scheduling grid.

Meh, unless you have it in your contract that you're expected to handle emergencies or urgencies on site, even if they're not your patients, I call BS on that. Another reason not to work at the VA for me.

OP, places are different. In the future always address it in interview. Me personally? I'm not sticking around until 5 if my last patient leaves at 2:30 unless part of my job responsibilities is to see emergencies. I can fill scripts from home if needed but no reason to sit around my office.

 

[Mad Jack]

As an employer and an outpatient psychiatrist, I always say, it's never a bad idea to ask specific questions (e.g. such as when you were expected to be on site during work hours). I'm assuming the reason they have that expectation is in case matters come up such as same day patient appointments, urgent messages and other matters you can bill for and generate revenue for the clinic for. Is there any reason you cannot continue to generate revenue off site? For example, maybe certain insurances are no longer reimbursing for telehealth from patient being at home? Because if you are still able to get billable productivity done, your employer might still be happy about that. Although, as an employer, I think they also should have held their end of the communication by being specific as possible about matters like that. When I worked at the VA, I stayed on site whether I had patients scheduled or not during the tour. I just assumed a 0.5 FTE was a 0.5 FTE and many vets preferred to come in person or sometimes staff would stop by my office.

I suppose it also depends on what you and your employer are looking to get out of the relationship. Most employers like to keep the psychiatrist full and busy because well....it means more money for them too. It applies both for if you are salaried or on a production model. Even the VA tracks your productivity. Which I can understand as well, because the money to at least meet the salary, has to come from somewhere and if the incentive is so low to see patients, the clinic would be at a net loss which is unsustainable. For your question about longer appointments, I've seen most employers be ok with that as long as it is discussed in advance and some employers are more strict than others about asking the provider accurately bill the time. For example, if you had a 45 min visit, they want to see you bill a 99213/99214 with 90836 (not 90833).

I've boarded on some newly graduated providers. Some of them were a bit surprised with attending life when they realized if they wanted to make x income, they needed to have x visits. One provider was working at a 0.6 FTE and was wondering why she was not getting 1.0FTE pay. I broke down the RVUs for her and we discussed other employment models and it started to sink in. At least in my residency, our clinic days were nowhere near as busy as that of an attending. And I too was a bit surprised after graduation at how many patients a 1.0 FTE say, at the VA, had to see.

I've seen some pretty low patient numbers for VA outpatient in some areas, seems to really depend on where you're at. We're talking 12 being a busy day