Outpatient Psychiatry

[CTR]

As a 3rd year medical student, my experience with psychiatry has been limited to inpatient care. I really enjoyed this experience, and as a matter of fact, I have since moved psychiatry to the top of my list of specialties I'd like to pursue. (Prior to my psychiatry rotation, I had mainly been considering either FP or IM.)

My psychiatry preceptor suggested to me that if I do plan on becoming a psychiatrist, I should try to gain some outpatient experience early in my 4th year to see if it's something I would really like, because the vast majority of psychiatry is done in the outpatient setting. I have contacted several residency programs to inquire about 4th year rotations, but unfortunately, it seems that virtually all of them only allow students to see inpatients. I have even been told that outpatient care is typically reserved for 3rd year residents.

Maybe this is because students can learn much more about psychiatry from inpatients... really I don't know. But I wonder if anyone out there can please tell me what it's like to work as a general psychiatrist with outpatients on a daily basis? What types of disorders are commonly seen? How long is a typical office visit, and what usually takes place with each encounter? Any insight would be greatly appreciated. Thank you.

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[OldPsychDoc]

I posted this almost 3 years ago--still seeing most of these folks regularly. I repost it, just because it gives some idea of the variety. Keep in mind that for me it is only half (actually a bit less) of my practice. I usually see a 1-hour intake, then 6-8 15-25 minute revisits--some are straight med checks, some have a bit more medical coordination of care, some a bit more therapeutic content--CBT- or DBT-lite.

Moving on to outpatient in the afternoon, my new patient intake is a young male, sober 3 months after 6 years of HEAVY marijuana use. He's paranoid, depressed and having panic attacks, and if he relapses he goes to jail for 7 months, but otherwise he's doing pretty good--his wife is letting him move back in next month.
Let's see, after that I had revisits: a single mom living with her 4 teenagers and depressed because she can't work due to chronic back pain--Effexor's helping the depression, but not the self worth issues.
Then a retired accountant who's ready to taper off his antidepressants--he got on CPAP for his sleep apnea, and suddenly he feels awake during the day.
Then one of my Suboxone patients--really happy to be off the opiates, but spent 20 minutes dumping about the boyfriend who took off, left his bills, and hasn't been heard from in 2 months. She's also wondering if her mood swings could be hormonal and we talked another 10 minutes about getting a peri-menopause workup. (Guess I AM a real doctor after all! Good thing the accountant was a short visit--I'm still on schedule!)
Next, schoolteacher who wants out of her marriage--husband's blaming it on her history of bipolar disorder, but that's been under control for years. She's really just sick of him--and I've got no meds for that.
Finally, another depressed woman, mostly in remission, but some with new funky pelvic neuropathic pain syndrome of uncertain origin--we talk herpes, pelvic floor muscles, fibroids, and referred pain. Her primary wants to try amitriptylline for it, but she wanted to be sure that was ok with me first. More "real doctor" stuff--and an amazingly pleasant conversation in spite of the material.
.

In addition to these examples I might see referrals from our chem dep program--is the depression substance-induced, situational adjustment, or primary? I also get some med management of developmentally delayed folks from local group homes, or generally stable schizophrenics in the community, or the occasional panic disorder and OCD, plenty of personality disorder & chronic pain...etc.

I'm not surprised it's difficult to find rotations in this as a med student--so much of it is about the continuity with the patient.

 

[digitlnoize]

Thanks OPD! I wish a couple others would type up something similar...

I'm in a similar situation as the OP. Most of my 3rd year rotation was in a inpatient crisis unit, average LOS < 3 days, mostly child. I assumed that since most of our patients were being D/C'd with outpt follow up that I'd see a similar mix in outpt life. OPDs post correlates well with that theory.

That being said, I've asked a number of private psych docs if I could shadow them in their outpt practice for a day or so, but I haven't gotten any takers. They all give me the line about "Pt privacy, comfort, etc...". It is frustrating because I am primarily interested in having my own place one day and it'd be nice to have some mentors...

 

[OldPsychDoc]

Thanks OPD! I wish a couple others would type up something similar...

I'm in a similar situation as the OP. Most of my 3rd year rotation was in a inpatient crisis unit, average LOS < 3 days, mostly child. I assumed that since most of our patients were being D/C'd with outpt follow up that I'd see a similar mix in outpt life. OPDs post correlates well with that theory.

That being said, I've asked a number of private psych docs if I could shadow them in their outpt practice for a day or so, but I haven't gotten any takers. They all give me the line about "Pt privacy, comfort, etc...". It is frustrating because I am primarily interested in having my own place one day and it'd be nice to have some mentors...

As far as solo/small PP, you'll have plenty of time to find mentors in residency. I think you probably would find some community attendings who wouldn't mind a shadow, particularly in community mental health, VA, academic outpatient clinics. I've had med students from my inpatient setting follow me for an afternoon--I usually just tell the patient on the way in that "I have a student observing me today, will that be alright if she/he sits in?" 95% of the time it's no problem...

 

[CTR]

Thank you OldPsychDoc for your reply. That does give me an idea of what outpatient care is like; your description allows me to sort of "experience" in my mind a typical day.

I would also like to echo digitlnoize's comments and encourage other psychiatrists to post a description of an average day.

With respect to treating chronic pain, I wonder how often D.O. psychiatrists make use of osteopathic manipulation?

 

[nitemagi]

I think this is a major deficit in medical education, where most rotations are inpatient only. Kind of gives a skewed perspective as to what psychiatry really is, and neglects the appeal of psychotherapy. But I can also see the difficulty of shadowing, especially in 1:1 psychotherapy.

 

[CTR]

Any other psychiatrists out there who would like to describe a typical day?

 

[zac16125]

Thanks OPD! I wish a couple others would type up something similar...

I'm in a similar situation as the OP. Most of my 3rd year rotation was in a inpatient crisis unit, average LOS < 3 days, mostly child. I assumed that since most of our patients were being D/C'd with outpt follow up that I'd see a similar mix in outpt life. OPDs post correlates well with that theory.

That being said, I've asked a number of private psych docs if I could shadow them in their outpt practice for a day or so, but I haven't gotten any takers. They all give me the line about "Pt privacy, comfort, etc...". It is frustrating because I am primarily interested in having my own place one day and it'd be nice to have some mentors...

I just set up an psych rotation with one of the docs up here since MG's was booked for the month I wanted. From what I've heard about the rotation its mostly outpatient. Unfortunately the majority of the time is spent with the ARNP not the pyschiatrist himself, but others have told me they started seeing/treating patients on their own after the first week. Could be a good experience if you want an outpatient setting. I'll let you know how it goes. And if you're staying around the area next year I'll let you know if its worth doing an elective there.

 

[whopper]

What I like about outpatient psychiatry
1) You can establish a long-term treatment relationship with patients. You may have patients for years.
2) Patients are usually higher-functioning. After all they are stable enough to be in the community. This leads to more interaction based on psychotherapy.
3) You get a different mix of patients vs. the type you see in a long-term facility.

E.g.
Outpatient
Any disorder but more so depression, anxiety, Bipolar II disorder, ADHD, and Cyclothymia, personality disorders

Short-term inpatient
Any disorder but more so psychosis and Bipolar I disorder, people recovering from a recent bout of drug use, and borderline PD where the person is parasuicidal

Long-term inpatient
Hardly any anxiety DO patients, more so severe psychosis and mania and more so treatment-resistant psychosis, mania, and/or depression.

If you work in one clinical scenario, you usually only see patients of a sort. I currently work in a long-term and forensic unit, so seeing outpatients gives me variety of sorts. I would get a depression or anxiety DO patient only about 3-5 times the entire year in this setting.

What I don't like about outpatient
1) Phone calls you can't bill: You get a lot of patients calling the office and expecting you to talk to them as if it's an interview. No. You're not supposed to do interviews over the phone. Then often times they call, you call back and no one answers. They call back, you call back. You spend about 15 minutes a day doing phone tag.

2) You got a problematic patient? It's harder to "get rid of them" In inpatent, you discharge, it's over for all intents and purposes. You got a patient you don't like, you're going to see them again and again and again and again and again. In general, I like all my patients, but I do have some with some very frustrating characteristics. E.g one patient forgot to bring in his labs, so his enmeshed mother called the lab demanding for his labs to be faxed to my office while she stood in my office and refused to leave the office until the fax came in. 40 minutes later, and her forcing me to leave two patients waiting, they finally came in. I told her several times she could not hold the office hostage like that and I did consider calling the police to force her out.

If she ever pulls a stunt like that again, I will terminate that patient and/or call the police.

In inpatient, no one can ever do this. So simply call security, and security arrives in 1-2 minutes (if the hospital has competent security, some do not), and security escorts them out, or you "haldol" them. Inpatient? Nope. Call the police and they don't show up for 10-30 minutes. Then they show up and the risk of someone getting arrested is there.

Occasionally you get patients like this, or their overbearing family members.

3) You have to churn patients in and out. Yeah, I know same happens in inpatient, but at least in inpatient, you can go to your office and veg out for maybe 30 minutes to collect yourself now and then and you still get paid. In private oupatient, you don't see patients, you don't make money.

4) Inpatient: You can see the effect of the medication on a day-to-day basis, and sometimes patients are not good reporters of their improvement....leaving you in position in outpatient where you don't know what is going on.

Several patients fall into a zone where I can't tell if the disorder is GAD, Cyclothymia/Bipolar II, or ADHD and I don't have 24 hour observation. E.g. sx of poor sleep, easy distractibility, "racing thoughts", and poor concentration. In inpatient, you give a med, you can see what it does to the patient. In outpatient, you get a patient like I mentioned and then you give them the medication, and then the patient gives even more ambiguous answers as to the effect....E.g. "yeah the medication I think helped. I don't know how but I think it did, but my symptoms are just as bad.
Me: "But you said the medication helped. I don't understand. How did it help?"
Patient: "well yeah, I think I can concentrate better, but then again, I'm not sure. Maybe it helped."

6) You're more under the gun: You have to tell patients "time's up" when they are sometimes in the middle of a highly emotional episode. Why? Because you got another patient waiting to see you and if you make that other patient wait, then the entire schedule for the rest of the day is screwed.

 

[digitlnoize]

I just set up an psych rotation with one of the docs up here since MG's was booked for the month I wanted. From what I've heard about the rotation its mostly outpatient. Unfortunately the majority of the time is spent with the ARNP not the pyschiatrist himself, but others have told me they started seeing/treating patients on their own after the first week. Could be a good experience if you want an outpatient setting. I'll let you know how it goes. And if you're staying around the area next year I'll let you know if its worth doing an elective there.

That's awesome. Let me know how it goes. I'm trying to stay up here as much as I can, to be near family, but if it's a slam bang awesome rotation, then it might be worth it...I'm hoping my next month at the child place here will answer my questions. Oddly, the clin-ed office at school tells me that the adult inpatient state hospital up here is already an affiliate No idea who set that up, but I'll probably take advantage of it...

I wonder if whopper (or any of the other excellent attendings here) would ever take a student for a rotation?

Speaking of, whopper's excellent post brings up a question I've been wondering about: How do psychiatrists handle the issue of being alone with patients, particularly those of the opposite sex. Do you ever worry about the "he said/she said" stuff, and if so, how do you handle it in the outpatient world, particularly if you're solo?

 

[kcrd]

Any other psychiatrists out there who would like to describe a typical day?

I am an outpatient psychiatrist in an academic practice setting, but my job is 100% clinical. I am still building my patient load, so on an average day I will see 2 new patients for 90 minutes each, and about 8 follow-up patients for 20-30 minutes each. I do mostly medication management with some basic supportive therapy. I see a variety of diagnoses, but common things are common, of course, so most of my patients have GAD or MDD. I probably have a disproportionate number of adult ADHD patients - I have several college students. Most of my patients are high functioning. I occasionally supervise the resident clinics if one of the academic attendings has a scheduling conflict. Some days I spend much more time than I would like in phone trees with insurance companies asking them to pay for wellbutrin or lexapro, calling in prescriptions, faxing in refills, etc. We do not have ancillary staff to do this type of work. Overall, though it is an interesting, rewarding job.

 

[Doc Samson]

Any other psychiatrists out there who would like to describe a typical day?

I'm a CL doc and a department chair so I get to wear a few different hats in the course of the day. I typically see 4-5 new consults/day plus 4-5 follow-ups. A sampling of the past week includes:

Young woman with Rx opiate dependence, pregnant, adm with SDH after MVA

Capacity eval on a woman with an abscess (potentially 2ndary to IVDA) who wanted to leave for a few hours "to run errrands"

Young woman with complex neuropsych issues - likely neurodegenerative disease resulting in psychosis

Young man who stabbed himself in the chest multiple times while intoxicated after an argument with his girlfriend

Middle aged man with newly dx'ed lung CA s/p lobectomy now with alcohol w/d

Frequent flyer PD NOS with substance abuse adm after found down with fentanyl patch in his mouth

Scattered in between patients there are a few med student lectures, administrative meetings, and working on the articles/chapters that I'm currently juggling. A typical day runs from 9:30am to ~5:30 or 6. Pager is always on since I'm the "final word" on issues in the department.

 

[Cinnameg]

Doc Samson, I would like your job. How far into your career are you? Did you do a psychosomatics fellowship?

As far as outpatient shadowing goes, try private and try rural. I was able to spend a few days with a rural child psychiatrist and only one parent asked that I not be in the room.

 

[Doc Samson]

Doc Samson, I would like your job. How far into your career are you? Did you do a psychosomatics fellowship?

As far as outpatient shadowing goes, try private and try rural. I was able to spend a few days with a rural child psychiatrist and only one parent asked that I not be in the room.

Yes I did a CL fellowship. I'll be four years out from fellowship this July. I love my job - CL is the reason I chose to be a psychiatrist.

 

[CTR]

Thank you to all the docs who have shared. It's nice to gain some additional insight to what it's like working as a psychiatrist, to see how different everyone's jobs are and to learn about the ups and downs of practice.