Outpatient practice and direct messaging service

[hypnorpheus]

I am a PGY3 resident in an academic hospital. I always thought that I would work in an outpatient practice after residency and hopefully some point down the line have my own practice. I have enjoyed much of the last 6 months, which has been entirely outpatient aside from 1 issue. Our hospital Epic system has a direct patient communication messaging system (MyChart). I understand that it can be helpful in many instances, but it is fatiguing and draining to be essentially "on call" all the time.

My question for this forum is whether this type of a direct communication system is the norm in usual outpatient psychiatry practices?

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[Yoyomama88]

It is a pain in the ass but yea it's pretty common.ideally you work somewhere a nurse can answer most of the questions and only defer to you when necessary

 

[Shufflin]

It's the norm if you want it to be the norm. If not then not.

 

[Stagg737]

This is a huge reason why I hate outpatient. We also have MyChart and are expected to check it daily during the week (we’re in multiple clinics). I happened to inherit a ton of somatic and personality patients and receive 3-8 messages/calls/requests per day and at least several of them can be taken care of by nurses or patients demanding a response from a physician. We have a clinic pharmacist who has been very helpful since starting, but it really does feel like being on call 24/7.

I’m working less hours and technically have no real call, but I feel like the past six months have been the most stressful so far. Literally counting down the days for third year to end.

 

[Celexa]

I am a PGY3 resident in an academic hospital. I always thought that I would work in an outpatient practice after residency and hopefully some point down the line have my own practice. I have enjoyed much of the last 6 months, which has been entirely outpatient aside from 1 issue. Our hospital Epic system has a direct patient communication messaging system (MyChart). I understand that it can be helpful in many instances, but it is fatiguing and draining to be essentially "on call" all the time.

My question for this forum is whether this type of a direct communication system is the norm in usual outpatient psychiatry practices?

You shouldnt feel on call all the time because you should only be checking these messages at a convenient time of day to you and replying within an acceptable time frame (1-2 business days). You get to decide what is urgent, not the patient.

I recognize that reworking your mindset is easier said than done when residents are essentially conditioned to constantly be afraid they aren't doing a good enough job, but you don't do patients any favors when you teach them they can reach you anytime of day. Epic has a function that let's you reply but delay the time when the reply gets sent. I recommend using it so that patients don't ever get a sense you are replying to them in real time.

 

[robellis]

I am a PGY3 resident in an academic hospital. I always thought that I would work in an outpatient practice after residency and hopefully some point down the line have my own practice. I have enjoyed much of the last 6 months, which has been entirely outpatient aside from 1 issue. Our hospital Epic system has a direct patient communication messaging system (MyChart). I understand that it can be helpful in many instances, but it is fatiguing and draining to be essentially "on call" all the time.

My question for this forum is whether this type of a direct communication system is the norm in usual outpatient psychiatry practices?

As you progress and gain more experience, you become more comfortable taking your time when replying and so it’s not as draining. As long as you reply within 1-2 days, it is acceptable and it reinforces to the patient they will not get an instant response so they do it less often. Also, some patients won’t tolerate a delayed response and will naturally leave your practice which is also beneficial to you

 

[splik]

I don’t think you are expected to answer these kinds of messages outside of office hours. But having some sort of messaging service is better than getting lots of calls to return. Also the trick is to do as much stuff in appointments as possible and make sure refills etc are handled during appointments so there should be few reasons for pts to contact you in between appointments.

I will also say the kinds of patients that fill resident clinics are “red flag” patients who are being treated in resident clinics for a reason. All my outpatients have the secure messaging and also my direct line and email. I’m easy to get a hold of and for other physicians to directly contact me. They do not abuse it. I don’t have anyone covering my practice when I’m gone and I’m gone a lot. But I also see my patients very frequently and am very selective in the patients I accept for ongoing care.

 

[Sushirolls]

Similar to Splik, I have mostly respectful patients. A few instances here and there but those were then talked about during appointments. Basically those patients were intoxicated when the typed out messages. I have one patient with OCD symptoms that is heavy on the messages, but as symptoms are improving and meds being dialed in messages are dropping.

I usually triage the messages as something quick and simply respond back. Or I encourage a more quick follow up to discuss during the appointment. Much rarer are the messages that warrant or prompt an urgent phone call from me.

In essence, Resident clinics are not private practice clinics.

I use Luminello and have the messaging feature turned on by default for every patient. I like the fact that if I had a patient who was abusing it I could discuss the need before hand of turning it off in trade for having frequent close follow ups. This hasn't been needed so far.

I'm in solo with no other coverage and do take vacations (but check the messages during the vacations) and don't really consider the messaging feature to be a drain.

 

[Candidate2017]

I am a PGY3 resident in an academic hospital. I always thought that I would work in an outpatient practice after residency and hopefully some point down the line have my own practice. I have enjoyed much of the last 6 months, which has been entirely outpatient aside from 1 issue. Our hospital Epic system has a direct patient communication messaging system (MyChart). I understand that it can be helpful in many instances, but it is fatiguing and draining to be essentially "on call" all the time.

My question for this forum is whether this type of a direct communication system is the norm in usual outpatient psychiatry practices?

Academic faculty usually have zero idea on how to run a practice. You are insulating them from having to deal with patient hassle, so faculty have an incentive to violate boundaries and give the impression that you need to be on call 24/7 for their patients under the guise of "good care."

Patient and practice management is something you have to develop on your own. For example, from Day 1 of residency clinic, I pretended it was my solo cash practice and ran things accordingly. Think about the top reasons why patients contact you and have a process in place to preempt or handle such contact. I have a discussion with every new patient on when, why, and how to contact me (no EMR messages). Some new patients may contact me once or twice for BS calls that take just a few minutes before they adjust to how I do things.

Paradoxically, when patients know I personally return any and all legitimate calls (again, pretending it is my solo cash practice), they are less likely to call.

 

[dl2dp2]

What if you just don't answer? LOL Are you gonna get fired? What if you OWN the practice? Are you gonna fire yourself?

 

[Stagg737]

In essence, Resident clinics are not private practice clinics.

This is nice to hear, but hard to really gauge when you're in the middle of PGY-3 year. At one location I'm at my patient population is mostly great and those days aren't bad. At one of my clinics, my panel is notorious among our PGY-3's and 4's as having quite a few ridiculous patients. I'd like to think that outpatient isn't bad, but I find a lot of patients at that clinic to be particularly draining especially when they have access to messaging through EMR.

What if you just don't answer? LOL Are you gonna get fired? What if you OWN the practice? Are you gonna fire yourself?

Probably not fired, but it can become a hassle. One of my patients who needed strict boundaries placed got so angry that I stopped responding to BS messages that she contacted or residency office directly to complain to the PC/PD. I didn't get in trouble, but explaining to my PD why this patient felt the need to go directly the to head of the program to complain was not something I particularly enjoyed (though our PD was very understanding).

 

[dl2dp2]

Probably not fired, but it can become a hassle. One of my patients who needed strict boundaries placed got so angry that I stopped responding to BS messages that she contacted or residency office directly to complain to the PC/PD. I didn't get in trouble, but explaining to my PD why this patient felt the need to go directly the to head of the program to complain was not something I particularly enjoyed (though our PD was very understanding).

I would argue setting appropriate boundaries to engage patients and yet be therapeutic is one of, if not THE, core skills of outpatient psychiatry. What you referring to as "hassle" is really learning.

 

[Merovinge]

What if you just don't answer? LOL Are you gonna get fired? What if you OWN the practice? Are you gonna fire yourself?

At my current job they just changed all our quality pay metrics without warning/discsussion (which is a substantial portion of our pay) to be related to answering any phone calls, portal messages, clearing labs/imaging within 48 hours. This includes the weekend, such that any doctor who has any of these things come back Friday is delinquent by Monday. This forces you to work on the weekends or sacrifice tens of thousands in pay. Now mind you I don't plan on staying at this job much longer, but this is what people are facing down. I would be miserable doing this for decades.

 

[dl2dp2]

At my current job they just changed all our quality pay metrics without warning/discsussion (which is a substantial portion of our pay) to be related to answering any phone calls, portal messages, clearing labs/imaging within 48 hours. This includes the weekend, such that any doctor who has any of these things come back Friday is delinquent by Monday. This forces you to work on the weekends or sacrifice tens of thousands in pay. Now mind you I don't plan on staying at this job much longer, but this is what people are facing down. I would be miserable doing this for decades.

Yup. The keyword is owning your practice. Still, if you just don't meet qual metrics, your pay gets docked--it just means they reduced your pay. So it's a matter of choice as to whether you meet these metrics or not. That's just a psychological trick. The *effective* salary is lower. This can be considered logically, rather than emotionally, during any future salary negotiation.

Management actually has little in ways of their methods to make employees do things. Either they fire you (which is very costly for everyone involved), or they dock your pay or incentivizes you with extra pay, nag you, or they grant ownership (i.e. profit share). There's usually *very little* management can do with employee passive resistance, especially at a large organization. With the right psychological makeup and interpersonal skills, and effective use of institutional regulations (vacations, sick days, etc), many bad jobs can be tuned in a way that's very pleasant for everyone.

 

[sloh]

Yup. The keyword is owning your practice. Still, if you just don't meet qual metrics, your pay gets docked--it just means they reduced your pay. So it's a matter of choice as to whether you meet these metrics or not. That's just a psychological trick. The *effective* salary is lower. This can be considered logically, rather than emotionally, during any future salary negotiation.

Management actually has little in ways of their methods to make employees do things. Either they fire you (which is very costly for everyone involved), or they dock your pay or incentivizes you with extra pay, nag you, or they grant ownership (i.e. profit share). There's usually *very little* management can do with employee passive resistance, especially at a large organization. With the right psychological makeup and interpersonal skills, and effective use of institutional regulations (vacations, sick days, etc), many bad jobs can be tuned in a way that's very pleasant for everyone.

While it may be costly to to fire you, they won't hesitate to do it as long as there are other hungry physicians who will willingly toe the line.

 

[Candidate2017]

Probably not fired, but it can become a hassle. One of my patients who needed strict boundaries placed got so angry that I stopped responding to BS messages that she contacted or residency office directly to complain to the PC/PD. I didn't get in trouble, but explaining to my PD why this patient felt the need to go directly the to head of the program to complain was not something I particularly enjoyed (though our PD was very understanding).

A kindergartener politely declines to hand over candy to a bully, gets punched by the bully, and then gets dragged into the principal's office for "fighting". Ah yes, residency.

 

[dl2dp2]

While it may be costly to to fire you, they won't hesitate to do it as long as there are other hungry physicians who will willingly toe the line.

Right, except for many organizations the issue is right now is retaining physicians. They could replace you with an NP, and many are, but hiring NPs have their own issues. For one thing, if you think physicians can be passive-aggressive, NPs can be an order of magnitude more so. The value add there structurally often isn't all that wonderful.

 

[Candidate2017]

I would argue setting appropriate boundaries to engage patients and yet be therapeutic is one of, if not THE, core skills of outpatient psychiatry. What you referring to as "hassle" is really learning.

I think they are referring to the hassle of having to explain to the PD why they enforced boundaries.

The resident is not allowed to set boundaries without fear of having to report to the principal's office, and the patient is not allowed to tolerate boundaries because they can cry out to the PD at the first sign of distress. Infantilization of both doctor and patient.

 

[FlowRate]

You shouldnt feel on call all the time because you should only be checking these messages at a convenient time of day to you and replying within an acceptable time frame (1-2 business days). You get to decide what is urgent, not the patient.

I recognize that reworking your mindset is easier said than done when residents are essentially conditioned to constantly be afraid they aren't doing a good enough job, but you don't do patients any favors when you teach them they can reach you anytime of day. Epic has a function that let's you reply but delay the time when the reply gets sent. I recommend using it so that patients don't ever get a sense you are replying to them in real time.

This is advice I should have taken when I first started this attending job. Before I got fully up to speed / schedule fully opened I had plenty of time to call and message immediately. But those patients now expect that same sort of response. Delaying to 1 business day (when it's not actually urgent) just to set an expectation is actually a great idea.

 

[Sushirolls]

While it may be costly to to fire you, they won't hesitate to do it as long as there are other hungry physicians who will willingly toe the line.

Yes, this. A Big Box shop that pushes this kind of scat is the same institution that will cut off their nose to spite their face. I have seen this too many times. Logic doesn't resonate with the Big Box shop. They don't care if they fire a good Psychiatrist or strongly push them out the door to open up revolving door of new grad fresh meat, and ARNPs.

The concept of true Human Resources to build and value the people you have for mitigation of turnover and other indirect costs is lost upon these places.

 

[tr]

Probably not fired, but it can become a hassle. One of my patients who needed strict boundaries placed got so angry that I stopped responding to BS messages that she contacted or residency office directly to complain to the PC/PD. I didn't get in trouble, but explaining to my PD why this patient felt the need to go directly the to head of the program to complain was not something I particularly enjoyed (though our PD was very understanding).

Wow this sounds like an incredibly savvy patient. I can't imagine most patients in the resident clinics would be able to identify the PD or understand the residency training structure well enough to direct a complaint there.

 

[Stagg737]

I would argue setting appropriate boundaries to engage patients and yet be therapeutic is one of, if not THE, core skills of outpatient psychiatry. What you referring to as "hassle" is really learning.

The hassle of it wasn't so much with dealing with her (it was a hassle, but some patients are), it was with having the PD get involved and feel like I need to justify the boundaries. It was fine, but just another stressor that residents shouldn't have to deal with. I agree that setting boundaries is important and I probably need to be more strict with this in general, but I'll also say that I have more patients than I'd like who I would have either fired by now or never started seeing if I were in PP.

Wow this sounds like an incredibly savvy patient. I can't imagine most patients in the resident clinics would be able to identify the PD or understand the residency training structure well enough to direct a complaint there.

It's actually surprisingly easy to find our coordinator's e-mail as it's on the bottom of the homepage when you google XYZ psychiatry residency. Our PC just forwarded it to our PD because she didn't know what to do with it.

 

[psychacad]

I am a PGY3 resident in an academic hospital. I always thought that I would work in an outpatient practice after residency and hopefully some point down the line have my own practice. I have enjoyed much of the last 6 months, which has been entirely outpatient aside from 1 issue. Our hospital Epic system has a direct patient communication messaging system (MyChart). I understand that it can be helpful in many instances, but it is fatiguing and draining to be essentially "on call" all the time.

My question for this forum is whether this type of a direct communication system is the norm in usual outpatient psychiatry practices?

I'm not sure how having a 'direct patient communication system' means being on-call all the time.

It's no different than patients calling and leaving a voice message. It's really important to establish boundaries in outpatient for you and for the patient. That means, don't check/reply to messages all the time, but have a specific time of the day for that. You can make that clear to patients when you see them and if there is something that cannot wait they really should be calling 911. If someone is abusing the system then you should directly discuss it with them. Think of it as an opportunity to actually make a breakthrough in the treatment because it really is part of the pathology that you both want to address.

There is a learning curve in outpatient and, as mentioned, boundaries are probably the most important. Many patients will want to abuse them and that's how you know you got a foothold in their pathology.

 

[AD04]

At my current job they just changed all our quality pay metrics without warning/discsussion (which is a substantial portion of our pay) to be related to answering any phone calls, portal messages, clearing labs/imaging within 48 hours. This includes the weekend, such that any doctor who has any of these things come back Friday is delinquent by Monday. This forces you to work on the weekends or sacrifice tens of thousands in pay. Now mind you I don't plan on staying at this job much longer, but this is what people are facing down. I would be miserable doing this for decades.

Does management expect to retain physicians?

 

[clausewitz2]

I was very deliberate in telling people that I will always respond to their messages. By EOB the next business day. Over time you learn whose messages you can respond to as soon as you happen to see them and it won't cause a problem, and who is going to respond to this by barraging your inbox a dozen times that week. The same is true of things like late/no-show fees - some people you can cut some slack every now and again and it'll be fine, and some people will be serial offenders if you don't stick rigidly to whatever policy they signed.

Of course, I also work with a lot of people with OCD and end up telling a fair number of people on a weekly basis "if you ask a question once, I'll answer it best I can, but if you ask the same question or a really similar one a second time, I'm not going to address it until you can tell me how much it's coming from not knowing information and how much is coming from wanting me to make you feel better." I also frequently talk family members through answering distressed inquiries about, say, whether they think their spouse is a pedophile with irrelevancies like "I love you" or "you're such a good cook." I get a lot of practice at not letting other people's anxiety become my anxiety.

 

[clausewitz2]

Does management expect to retain physicians?

I love how it wasn't 24, or 72, but definitely 48, just so physicians could know that management was saying "F you and your weekends."

 

[hallowmann]

This is a huge reason why I hate outpatient. We also have MyChart and are expected to check it daily during the week (we’re in multiple clinics). I happened to inherit a ton of somatic and personality patients and receive 3-8 messages/calls/requests per day and at least several of them can be taken care of by nurses or patients demanding a response from a physician. We have a clinic pharmacist who has been very helpful since starting, but it really does feel like being on call 24/7.

I’m working less hours and technically have no real call, but I feel like the past six months have been the most stressful so far. Literally counting down the days for third year to end.

You should check out the primary care side. 3-8 messages per day are nothing.

As for the messaging PD, I've had patients send me emails and CC my PD in them when they work in our system. If not urgent, I typically don't respond or wait at least 48 hrs, with a message saying "sorry, its best not to email me and to send me a MyChart message or call the clinic, because those get triaged" at the end. If its urgent, I don't wait, but I include that line. The first time I did it, my PD actually complimented me on "boundary building".

Other residents and even some attendings here (mostly CAP) freely give out their email to patients. Personally, that's too much for me. I don't need that liability or work, MyChart is more than enough.

For the people that message novels every week, I say "I really want to discuss this with them at a visit" and forward them to to scheduling. For ones with demands, I limit to X number per Y amount of time, and they toe the line or don't get a real response.

Messaging is unfortunately part of the job, but I'd much rather that than calls which could take forever.

Does management expect to retain physicians?

I assume the answer is no.

 

[Stagg737]

You should check out the primary care side. 3-8 messages per day are nothing.

As for the messaging PD, I've had patients send me emails and CC my PD in them when they work in our system. If not urgent, I typically don't respond or wait at least 48 hrs, with a message saying "sorry, its best not to email me and to send me a MyChart message or call the clinic, because those get triaged" at the end. If its urgent, I don't wait, but I include that line. The first time I did it, my PD actually complimented me on "boundary building".

Other residents and even some attendings here (mostly CAP) freely give out their email to patients. Personally, that's too much for me. I don't need that liability or work, MyChart is more than enough.

For the people that message novels every week, I say "I really want to discuss this with them at a visit" and forward them to to scheduling. For ones with demands, I limit to X number per Y amount of time, and they toe the line or don't get a real response.

Messaging is unfortunately part of the job, but I'd much rather that than calls which could take forever.


I assume the answer is no.

Won't go into too much detail, but it's not the number of messages, just the nature of them in conjunction with this clinic's policies that start to wear you down. Unless there's no shows (which are far fewer now that pretty much everything is telehealth) it's a struggle to stay on track with a schedule as it is. If I get more than 1 or 2 complex messages that need to be addressed, I typically end not getting a lunch or staying an hour or two late.

By complex messages I mean things which may lead to hospitalization if not addressed within a few days. One of my clinics is very reasonable, another is hit or miss (but other staff handles all messages), but the one I'm talking about my patient panel just has an abnormally high number of high acuity/complicated patients (even by CMHC standards). Part of it is just the anticipation of "when's the next message coming" that feels like I'm always on call.

 

[hallowmann]

Won't go into too much detail, but it's not the number of messages, just the nature of them in conjunction with this clinic's policies that start to wear you down. Unless there's no shows (which are far fewer now that pretty much everything is telehealth) it's a struggle to stay on track with a schedule as it is. If I get more than 1 or 2 complex messages that need to be addressed, I typically end not getting a lunch or staying an hour or two late.

By complex messages I mean things which may lead to hospitalization if not addressed within a few days. One of my clinics is very reasonable, another is hit or miss (but other staff handles all messages), but the one I'm talking about my patient panel just has an abnormally high number of high acuity/complicated patients (even by CMHC standards). Part of it is just the anticipation of "when's the next message coming" that feels like I'm always on call.

Hmm, so that's a bit different. That's less of an issue with messages per se and more of an issue with the acuity of patients in the outpatient setting with limited resources.

This is probably one of the harder things to get used to for a lot of people. I've seen many residents swear off outpatient because of this. Its one thing taking care of acute patients in the controlled setting of an inpatient unit, but with those patient's whose acuity borders on admission, you have none of those controls or safe guards.

I'm not sure if it helps, but this is a harder thing to learn and a harder thing to get used to. Just know that ultimately your job is to try your best to help the patient. You are not inherently in charge of the outcome, especially when dealing with patients who may be non-adherent or have their own social determinants that make them higher risk. Work hard, get to know the resources around you that you can utilize, be they VNAs, partial programs, ACT teams, etc., and recognize that in the outpatient setting you can only do so much besides recommending treatment options and ultimately admission or commitment in worse cases.

I would carve out a time to check for these messages. Like give yourself a 30 min lunch and use the second half hour for these messages (its better to address at least some during the day while you could say schedule a close follow up or make other changes) or give yourself an hour in the morning. Try to stop anticipating them, and just tell yourself that you'll address them at X time everyday. Setting that boundary for yourself should be one way to take yourself out of feeling like you are constantly on call and put it more in your control.

 

[Merovinge]

Does management expect to retain physicians?

There was huge uproar about it, like many of the other anti-physician policy that have rolled out in a short period of time. The organization actually sort of expects significant turnover to leave only the most lapdog of MD's left who lack pride or ambition to seek employment elsewhere is what I gather of their business model. I think a number of health care systems seem to work like this these days.

 

[AD04]

There was huge uproar about it, like many of the other anti-physician policy that have rolled out in a short period of time. The organization actually sort of expects significant turnover to leave only the most lapdog of MD's left who lack pride or ambition to seek employment elsewhere is what I gather of their business model. I think a number of health care systems seem to work like this these days.

Physician recruitment isn't easy, which is why staffing agencies are paid a lot of money. I'm very curious as to what type of place has so many physicians where they can burn through a lot of them without harming their business. You must be in a major metropolitan area but even then I can't imagine what place has so many physicians lining up to work.

 

[psychacad]

Physician recruitment isn't easy, which is why staffing agencies are paid a lot of money. I'm very curious as to what type of place has so many physicians where they can burn through a lot of them without harming their business. You must be in a major metropolitan area but even then I can't imagine what place has so many physicians lining up to work.

Some places are so bad that they know that they won't be able to retain doctors anyhow, so might as well screw the doctors while they are still there and keep the cycle of feeding on new victims.

 

[Sushirolls]

Some places are so bad that they know that they won't be able to retain doctors anyhow, so might as well screw the doctors while they are still there and keep the cycle of feeding on new victims.

That's the best thing I've been able to come up with. It's just mind boggling.

I also have a working theory about the clinical staff - midmanagment - and upper management.

Upper management doesn't really care, only does just enough to slash things to improve the budget on paper just enough to show they did something, made some level of "progress." Similar to how politicians push thru bills that have flashy headline but really only add bureaucratic bloat. They are only looking for the next Big Box shop to move on to. Despite the rhetoric and hype when they come in, they are only temporary. In some ways they have to move on, because a Big Box shop is like a hot potato, you don't want to be the one left holding it get blamed for big issues XYZ that just ends your career in upper management. Why be the problem originator when you can frequently pollinate new places and be the positive shiny problem solver?

Midmanagment sticks around forever and seldom gets replaced because they are the locals, the people who truly stay and don't want the promotions that would lead to their needing to move, and their incompetence is tolerated, because the upper management doesn't care about replacing them as long as they do their bidding for the bigger agendas. That is enough to retain them even if the folks beneath them are suffering from their incompetence.

Docs are not valued. Midlevels on paper are interchangeable and more likely to do what they are told. Therefore, there is no sense of value between physician and midlevels, and with this lower value, they are chewed up and spit out with a goal of distilling down those who don't care, or simply say yes to what they are told. Fresh grads are often the new meat for the grinder. Upper management doesn't really care about the history of unfilled positions or staff turnover because they are only getting the snap shot of their brief tenure. At best they consult 3rd party consultant firms, which no surprise, compare them to other Big Box shops and say they have an average number of turnover that is statistically acceptable industry wide. Despite the people in the clinical mines, know that Bob Beta, and Sigma Sally left for good reason and things that could have easily been prevented had midmanagement and upper management listened and made simple real world changes.

The saga of all this... so glad I'm out of the Big Box shop arena.

 

[myPsychAlt]

I don’t think you are expected to answer these kinds of messages outside of office hours. But having some sort of messaging service is better than getting lots of calls to return.

This. I'd rather be able to read out the patient's complaint than having to listen to their rambling, often angry messages.

(or you can work for the VA where at most sites you'll be expected to do both. Any streamlining of the patient messaging system is a sign that you hate veterans, of course)

 

[myPsychAlt]

Probably not fired, but it can become a hassle. One of my patients who needed strict boundaries placed got so angry that I stopped responding to BS messages that she contacted or residency office directly to complain to the PC/PD. I didn't get in trouble, but explaining to my PD why this patient felt the need to go directly the to head of the program to complain was not something I particularly enjoyed (though our PD was very understanding).

Also another thing that doesn't go away at the VA.... and now we have the White House hotline to answer to!.

 

[AD04]

Some places are so bad that they know that they won't be able to retain doctors anyhow, so might as well screw the doctors while they are still there and keep the cycle of feeding on new victims.

How are these bad places able to attract new victims in the first place? Residents talk and know which places are good and which places are bad. I was part of the grapevine as a resident and even after residency, I still talk to my former colleagues and talk about which places are good and which ones are bad.

So to combat their negative reputation, they may have to spend on recruiting. And if they spend so much on recruiting, they should care if their physicians stay or not.

I keep tabs of the places I interviewed at and places I worked at in the past and all but one of them have not hired a new physician since my last contact.

 

[psychacad]

How are these bad places able to attract new victims in the first place? Residents talk and know which places are good and which places are bad. I was part of the grapevine as a resident and even after residency, I still talk to my former colleagues and talk about which places are good and which ones are bad.

So to combat their negative reputation, they may have to spend on recruiting. And if they spend so much on recruiting, they should care if their physicians stay or not.

I keep tabs of the places I interviewed at and places I worked at in the past and all but one of them have not hired a new physician since my last contact.

I don't think it's always easy to tell malignant places from just an interview. Fresh grads are also easy victims; not everyone is trained or knows what to look for. My guess is that it probably takes even more effort/money to change the conditions that make doctors want to leave in the first place and so high turnover becomes just part of the work culture.

 

[Merovinge]

Physician recruitment isn't easy, which is why staffing agencies are paid a lot of money. I'm very curious as to what type of place has so many physicians where they can burn through a lot of them without harming their business. You must be in a major metropolitan area but even then I can't imagine what place has so many physicians lining up to work.

It's actually the opposite, they are in a position to offer waivers for foreign physicians which is why this model works.

 

[Sushirolls]

Not everyone stays in the vicinity of their residency. Some people move to different states. New place means no local knowledge to tap into.

 

[Stagg737]

Hmm, so that's a bit different. That's less of an issue with messages per se and more of an issue with the acuity of patients in the outpatient setting with limited resources.

This is probably one of the harder things to get used to for a lot of people. I've seen many residents swear off outpatient because of this. Its one thing taking care of acute patients in the controlled setting of an inpatient unit, but with those patient's whose acuity borders on admission, you have none of those controls or safe guards.

I'm not sure if it helps, but this is a harder thing to learn and a harder thing to get used to. Just know that ultimately your job is to try your best to help the patient. You are not inherently in charge of the outcome, especially when dealing with patients who may be non-adherent or have their own social determinants that make them higher risk. Work hard, get to know the resources around you that you can utilize, be they VNAs, partial programs, ACT teams, etc., and recognize that in the outpatient setting you can only do so much besides recommending treatment options and ultimately admission or commitment in worse cases.

I would carve out a time to check for these messages. Like give yourself a 30 min lunch and use the second half hour for these messages (its better to address at least some during the day while you could say schedule a close follow up or make other changes) or give yourself an hour in the morning. Try to stop anticipating them, and just tell yourself that you'll address them at X time everyday. Setting that boundary for yourself should be one way to take yourself out of feeling like you are constantly on call and put it more in your control.

Yea, there's more to it than the messaging system, but it just feels like something that's constantly looming overhead that wasn't an issue before outpatient year. Time management and efficiency is something I'm constantly working on, and adjusting to outpatient when there is a set and inflexible schedule has been more challenging for me.

 

[AD04]

It's actually the opposite, they are in a position to offer waivers for foreign physicians which is why this model works.

That is something I haven't considered as it doesn't apply to me. Is it hard for foreign physicians to find work?

 

[AD04]

That's the best thing I've been able to come up with. It's just mind boggling.

I also have a working theory about the clinical staff - midmanagment - and upper management.

Upper management doesn't really care, only does just enough to slash things to improve the budget on paper just enough to show they did something, made some level of "progress." Similar to how politicians push thru bills that have flashy headline but really only add bureaucratic bloat. They are only looking for the next Big Box shop to move on to. Despite the rhetoric and hype when they come in, they are only temporary. In some ways they have to move on, because a Big Box shop is like a hot potato, you don't want to be the one left holding it get blamed for big issues XYZ that just ends your career in upper management. Why be the problem originator when you can frequently pollinate new places and be the positive shiny problem solver?

Midmanagment sticks around forever and seldom gets replaced because they are the locals, the people who truly stay and don't want the promotions that would lead to their needing to move, and their incompetence is tolerated, because the upper management doesn't care about replacing them as long as they do their bidding for the bigger agendas. That is enough to retain them even if the folks beneath them are suffering from their incompetence.

Docs are not valued. Midlevels on paper are interchangeable and more likely to do what they are told. Therefore, there is no sense of value between physician and midlevels, and with this lower value, they are chewed up and spit out with a goal of distilling down those who don't care, or simply say yes to what they are told. Fresh grads are often the new meat for the grinder. Upper management doesn't really care about the history of unfilled positions or staff turnover because they are only getting the snap shot of their brief tenure. At best they consult 3rd party consultant firms, which no surprise, compare them to other Big Box shops and say they have an average number of turnover that is statistically acceptable industry wide. Despite the people in the clinical mines, know that Bob Beta, and Sigma Sally left for good reason and things that could have easily been prevented had midmanagement and upper management listened and made simple real world changes.

What you wrote reminds me of something I read a long time ago:

The Gervais Principle, Or The Office According to “The Office”

My neighbor introduced me to The Office back in 2005. Since then, I’ve watched every episode of both the British and American versions. I’ve watched the show obsessively because I&#8217…

www.ribbonfarm.com

 

[Merovinge]

That is something I haven't considered as it doesn't apply to me. Is it hard for foreign physicians to find work?

It depends on H1B sponsorship versus J waiver positions but certainly the overall answer to that is yes. There are further barriers based on appearance/accent that assuredly play a role as well but I'm speaking only the fees and legal issues.

 

[psychacad]

It depends on H1B sponsorship versus J waiver positions but certainly the overall answer to that is yes. There are further barriers based on appearance/accent that assuredly play a role as well but I'm speaking only the fees and legal issues.

It's not hard to find a job, but if you're J1 you're just restricted to certain areas and employers by law.

When I was still on a visa I got a couple of PP offers with H1b/green card sponsorship right after residency in San Diego, lol. Even for those on a visa the market is good. It's just hard to know what the work is really like without first hand knowledge.