Outpatient year

[Stagg737]

I'm now 2 months into my outpatient year and have finally started hitting a good groove with outpatient clinics. I'm actually not minding outpatient nearly as much as I thought I would, but I see a huge amount of variation between the clinics that I work in and definitely look forward to some days more than others. It's got me wondering what outpatient year is like at various programs and I was hoping to find out what "normal" expectations are in terms of the PGY-3 year.

So for those who've done their outpatient year, what are your clinics like? Things I'm curious about are number of different settings/clinics you work in, time for f/ups and new evals, total patients per day, number of no-shows, average hours spent in clinic per day, patient population/demographics (lots of variety or just a ton of trainwrecks?), staffing policies, EMR(s), amount of time spent responding to patients calling with questions/problems between appointments, supervision time/frequency, etc. If 3rd years are taking call (other than the 3 required ACGME days) that would also be interesting to know as well.

For example:

My program has 3 clinics that we rotate through, a CMHC, a VA, and our academic center and we use Cerner, CPRS, and Epic at each one respectively.
We have 30 min f/ups in each clinic and 60 minutes for new evals at the CMHC and 90 minutes at the VA and academic clinics.
I generally see 10-12 patients at the VA, 6-8 at the CMHC and academic clinics d/t no-shows.
Days technically end at 5, but I don't like taking work home so I'm usually gone by 6.

Our VA population gets really repetitive with a lot of PTSD, MDD, and surprisingly a lot of legitimate ADHD.
Academic program has better variety with a lot of exposure to various problems, but seems more like a "typical" outpt clinic where I see a lot of anxiety and patients with borderline traits or PD.
CMHC is very hit or miss, but typically either really sick people or people with questionable med regimens who keep coming back for controlled substances.

We're pretty independent at our VA and CMHC where we just have supervision once a day and otherwise don't have to check a patient out directly unless we have questions or the patient is really complex.
At our academic center we have to check out every. single. patient. to an attending before ending their encounter and efficiency of attending with staffing the patient can vary a lot.
I have minimal f/up with patients at our VA and CMHC and they're typically not calling with questions or concerns unless they're on a controlled substance. At our academic clinic, we have a lot more patients sending messages through the EMR or calling with questions/requests.

We also don't have any required call after 2nd year, so being done at the end of the day and having free weekends has been really nice. I've been surprised by how tolerable the outpatient year has (mostly) been so far, and I'm especially liking that there seems to be more variety in terms of what I'm prescribing than during my first two years. There are some things that are a huge pain that I'm wondering are consistent at other programs (immediately staffing every patient specifically) or if it's less common.

Sorry for the dissertation, I'm just genuinely curious about what others' experiences have been, especially since I'm still pretty interested in academia after I finish residency.

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[wolfvgang22]

Sounds like a pretty standard PGY3 to me. Staffing every single patient varies program to program and attending to attending. I never had to staff my patients except weekly and I was expected to choose one or two difficult cases to staff, no more most of the time. I actually asked for more staffing at various times but was told other residents needed more supervision. Thanks, I guess? Maybe I had halitosis, I don't know.

Of note, having ADHD symptoms is one reason some people join the military instead of going to college or learning a trade. They can't sit still or focus as teens unless made to or progress a job for long, so they enlist. People with untreated ADHD sometimes do a bit better in a structured military environment than otherwise. Most enlisted people are from disadvantaged backgrounds, too, their mothers smoked while pregnant, and they were never seriously screened for ADHD.

 

[reca]

CMHC: Use some ancient EMR that I'm not even sure about. Staff with the attending later in the week. 60 minute initial/30 minute f/u. Theoretically up to 12 a day but most I ever saw was 10. Usually closer to 6-8.

VA: CPRS. Staff that afternoon with the attending. 60 minute initial 30 minute f/u. Around 10 a day.

Academic: Cerner. Staff between patients. 90 minute intitial, 45 minute f/u. 1/2 day clinic, 4-5 patients.

Student Health: Cerner. Staff between patients.60 minute initial 30 minute f/u. Staff between patients. 1/2day clinic, but usually fully booked and low no-show rate, so 6-8 patients.

Then we have to do 6 hours of therapy.

We have call in 3rd and 4th year so about 1-2 weekend shifts a month. No nights

 

[Doctorows]

We staff every patient both at our academic center and VA clinics. 60 min new intakes and 30 min follow-ups at both.
We also do 7 hours of therapy weekly, plus group/couples therapy. Still have a month of night float and occasional weekend call.

 

[Psychresy]

What kind of clinics do you all have? Our program has child, geriatric, substance half days in addition to adult and VA. Didactics are 90 minutes a day Mon-Thur.

 

[Stagg737]

What kind of clinics do you all have? Our program has child, geriatric, substance half days in addition to adult and VA. Didactics are 90 minutes a day Mon-Thur.

We have the VA and CMHC one day per week and our academic clinic 2 days per week. The fifth day is a half day of didactics, then psychotherapy supervision and admin time in the afternoon. All 3 clinics are open to any patient over 18yo. We have a child fellowship at our program and can do an outpatient child elective if we want.

I also didn't really think about psychotherapy. We have 2 hours per week blocked off for therapy patients, but I believe we can request more if we want (psychotherapy has pretty minimal emphasis at my program).

 

[Candidate2017]

At our academic clinic, we have a lot more patients sending messages through the EMR or calling with questions/requests.

My co-residents prefer EMR messages because they are easier with which to respond. But ease of use is precisely why patients are prone to overusing EMR messages and pushing boundaries.

I tell my patients the phone is the best way to communicate with me. However patients rarely contact me. I think it is because I strive to do a thorough job communicating side effects to expect vs rare dangerous side effects, and the safety plan with new patients. I also communicate that refills are done at appointments and make sure established patients have plenty of refills. Non-urgent issues are addressed in session.

All patient messages are responded with a phone by end of day, if legitimate (safety, health, appointments). It's counterintuitive, but if patients feel they can pick up the phone and call you for important things, they are less likely to call you for BS things.

 

[NontradCA]

At my community based spot we do 1 day child, 4 adult, all at same clinic (we have multiple clinics, residents are assigned to one)

2 hour initial eval, 1 hour f/u, 1 hour psychotherapy (up to 3x/week) all remote at the moment. Psychotherapy also has its own group and individual supervision 1x/week. Otherwise supervision is slotted out for an hour each day, but it is generally anytime we have questions.

Didactics is 1 afternoon/week.

Call is 1 weekend every 6 weeks.

 

[Candidate2017]

I also didn't really think about psychotherapy. We have 2 hours per week blocked off for therapy patients, but I believe we can request more if we want (psychotherapy has pretty minimal emphasis at my program).

This is kind of a shame.

Psychotherapy helps patients understand themselves, helps you understand patients, helps you understand how your behavior helps or affects patients, and helps you modify patient behaviors with your own behaviors. Whether or not you "do" psychotherapy with patients isn't important, but your supervisors should push you to question and explore the dynamics between you and every patient interaction, as well as add insight.

 

[NontradCA]

At my community based spot we do 1 day child, 4 adult, all at same clinic (we have multiple clinics, residents are assigned to one)

2 hour initial eval, 1 hour f/u, 1 hour psychotherapy (up to 3x/week) all remote at the moment. Psychotherapy also has its own group and individual supervision 1x/week. Otherwise supervision is slotted out for an hour each day, but it is generally anytime we have questions.

Didactics is 1 afternoon/week.

Call is 1 weekend every 6 weeks.

Also have 2 hours of research/QI time. We see anywhere from 6-8 patients a day. Initially was staffing every patient, not so much anymore. Also have clinic specific didactics 1x/week.

New EMR. For issues clinic managers forwards to nurse who triage/call patient then forward it to us.

 

[Stagg737]

At my community based spot we do 1 day child, 4 adult, all at same clinic (we have multiple clinics, residents are assigned to one)

2 hour initial eval, 1 hour f/u, 1 hour psychotherapy (up to 3x/week) all remote at the moment. Psychotherapy also has its own group and individual supervision 1x/week. Otherwise supervision is slotted out for an hour each day, but it is generally anytime we have questions.

Didactics is 1 afternoon/week.

Call is 1 weekend every 6 weeks.

Wow, why so much time for f/ups? I've also never seen 2 hours slotted for new patients unless they were really complex or testing is being done. Seems like a lot of time for every new patient.

This is kind of a shame.

Psychotherapy helps patients understand themselves, helps you understand patients, helps you understand how your behavior helps or affects patients, and helps you modify patient behaviors with your own behaviors. Whether or not you "do" psychotherapy with patients isn't important, but your supervisors should push you to question and explore the dynamics between you and every patient interaction, as well as add insight.

We do discuss this with our attendings with certain patients and can always ask about it. I should have said psychotherapy has pretty little dedicated time at my program. Some of our attendings focus a lot more on the medication side while some address the psychological aspects more. Though I don't think it is emphasized nearly as much as at some programs and I'll likely do some 4th year electives involving psychotherapy.

 

[FlowRate]

Our 3rd year was 1/2 time outpatient (4th year also 1/2 time outpatient).

1.5 hours once a week for new intakes. 1 hour for transfer patient intakes. 30 minutes for follow-ups. About 5 hours of psychotherapy (5 patients) expected. Caseload/Psychopharm supervision at the time was once a week for 60 minutes where we mostly talk about 1-2 complex patients and ideally also just keep tabs on the rest of the patient list. 2 hours of psychodynamic supervision every week and 1 hour twice a month for CBT supervision.

No show rates for intakes (prior to covid) were surprisingly high. Lower during covid because less barrier to just sign on to Zoom. Don't have to staff any patients other than new patient intakes but attendings are usually around and available if something comes up and you need in-the-moment help. Amount of time spent answering pt stuff highly variable depending on caseload and resident neuroticism. It's usually 1-2 particularly time consuming patients, most other patients are usually not too much work.

Pretty good case mix. Partially by design (transfer patients are somewhat selected to still be in active treatment and diagnoses evenly distributed among the next class of residents.)

Typical residents would have seen about 70-90 unique outpatients by the end of their 4th year (including as coverage for another resident and cases that are eventually discharged from clinic due to treatment completion, lack of follow-up, or, more rarely, behavioral issues) and have an active caseload of about 35-55 patients. That was often enough to have our 1/2 time clinic slots pretty well utilized--not too much downtime while in outpt clinic.

It's kinda funny to go from that to now seeing 4 new patients per day every single day... (and potentially more starting in september.)

 

[NontradCA]

Wow, why so much time for f/ups? I've also never seen 2 hours slotted for new patients unless they were really complex or testing is being done. Seems like a lot of time for every new patient.



We do discuss this with our attendings with certain patients and can always ask about it. I should have said psychotherapy has pretty little dedicated time at my program. Some of our attendings focus a lot more on the medication side while some address the psychological aspects more. Though I don't think it is emphasized nearly as much as at some programs and I'll likely do some 4th year electives involving psychotherapy.

I think there was a resident who had previously had difficulty finishing up f/u in allotted time. It is overkill.

 

[clozareal]

Here's my PGY3 year. I also enjoyed it much more than I thought I would.

1. Didactics: One full day
2. Clinics: 3 half days of General Adult Psychiatry, 1 half day of Child Psych Clinic, 1 half day of a specialty clinic, 1 half day of longitudinal clinic for all of residency (specialty clinic, VA, or CMHC), 2 half days of electives. All of this is at an academic institution other than the longitudinal clinic and perhaps electives (VA or CMHC).
3. New intakes: One a week for general adult psych clinic for 90 minutes, one a week for child clinic for 180 minutes (90 minutes x2 weeks), one a week for longitudinal (60 minutes), maybe 1-2 a week for specialty clinics/electives (60 minutes). Staff with attending while patient is still there usually.
4. Follow-ups: 30 minutes for med management, 45 minutes for therapy. Max follow-ups are 7 per half day which is infrequent. Typical is about 3-4 follow-ups plus one therapy per half day of clinic. Attending comes in physically to staff patient at end of each appointment except for therapy (They watch via Zoom). This can also vary a lot in timing, quality, and disagreements with the previous or current plan made by the resident or another attending.
5. Typical number of patients per day for me was about 4-6 patients. My day starts at 8am and ends at 5pm. I almost never have work after 5pm (write quick notes, try to prep notes ahead of time during the previous days or during downtime that day for busy days)
6. No show rate: mine ended up being 12% from the end of the year data
7. Average hours spent in clinic per day: Average about 4 hours
8. Patient population: at CHMC it's usually homeless or those housed by government with lots of addiction, trauma, depression, bipolar, and personality disorders. At the academic institution, for my general clinic, lots of MDD, persistent depressive disorder, treatment resistant depression, GAD, PTSD, ADHD, bipolar disorders (got really good at using lithium and managing the typical side effects), OCD (lots of treatment resistant ones too so learned about many adjunctive agents), insomnia, disability consultations, and bariatric consultations. No primary addiction but lots of dual diagnoses. For my specialty clinics, I saw geriatric patients (dementia/MCI, some movement disorders), oncology patients, patients with psychosis (lots of clozapine and LAIs), children with autism and other neurodevelopmental disorders, bread and butter children/adolescent ADHD/MDD/GAD, did lots of ECT (6-8 patients per half day) and TMS (6-12 patients per half day). Residents will have different specialty clinics and electives. Several of my co-residents got really good experience with methadone and buprenorphine (wish I did), did group psychotherapy, went to state prisons, worked embedded in many different clinics (high-risk OB, HIV clinic, primary care), worked in an integrative clinic, sleep medicine clinic, and lots of different types of psychotherapy (couples, family, psychoanalytic, interpersonal, ACT, DBT, etc.).
9. Call: heavy during 3rd year... Several weeks of night float, 24 hour weekend calls about once a month, and around one evening shift every 1-2 weeks. I also moonlight a lot but that's of course not expected.
10. Technical stuff: EMR is Epic, spend about 30 mins to 1 hour per day following up on patient voicemails or messages between appointments, supervision for therapy is 3 hours per week, supervision for clinic is before, after, and/or in the middle of each clinic half day for 30 minutes to one hour, panel management supervision once every other week for one hour.
11. In total, my panel had about 80-100 unique patients, but many were new intakes and many were discharged for whatever reason (stable enough to go back to PCP, moved away, lost to follow-up), so that at any one time, I probably had an active caseload of 40-50 patients on my panel.

 

[hallowmann]

I'm now 2 months into my outpatient year and have finally started hitting a good groove with outpatient clinics. I'm actually not minding outpatient nearly as much as I thought I would, but I see a huge amount of variation between the clinics that I work in and definitely look forward to some days more than others. It's got me wondering what outpatient year is like at various programs and I was hoping to find out what "normal" expectations are in terms of the PGY-3 year.

So for those who've done their outpatient year, what are your clinics like? Things I'm curious about are number of different settings/clinics you work in, time for f/ups and new evals, total patients per day, number of no-shows, average hours spent in clinic per day, patient population/demographics (lots of variety or just a ton of trainwrecks?), staffing policies, EMR(s), amount of time spent responding to patients calling with questions/problems between appointments, supervision time/frequency, etc. If 3rd years are taking call (other than the 3 required ACGME days) that would also be interesting to know as well.

For example:

My program has 3 clinics that we rotate through, a CMHC, a VA, and our academic center and we use Cerner, CPRS, and Epic at each one respectively.
We have 30 min f/ups in each clinic and 60 minutes for new evals at the CMHC and 90 minutes at the VA and academic clinics.
I generally see 10-12 patients at the VA, 6-8 at the CMHC and academic clinics d/t no-shows.
Days technically end at 5, but I don't like taking work home so I'm usually gone by 6.

Our VA population gets really repetitive with a lot of PTSD, MDD, and surprisingly a lot of legitimate ADHD.
Academic program has better variety with a lot of exposure to various problems, but seems more like a "typical" outpt clinic where I see a lot of anxiety and patients with borderline traits or PD.
CMHC is very hit or miss, but typically either really sick people or people with questionable med regimens who keep coming back for controlled substances.

We're pretty independent at our VA and CMHC where we just have supervision once a day and otherwise don't have to check a patient out directly unless we have questions or the patient is really complex.
At our academic center we have to check out every. single. patient. to an attending before ending their encounter and efficiency of attending with staffing the patient can vary a lot.
I have minimal f/up with patients at our VA and CMHC and they're typically not calling with questions or concerns unless they're on a controlled substance. At our academic clinic, we have a lot more patients sending messages through the EMR or calling with questions/requests.

We also don't have any required call after 2nd year, so being done at the end of the day and having free weekends has been really nice. I've been surprised by how tolerable the outpatient year has (mostly) been so far, and I'm especially liking that there seems to be more variety in terms of what I'm prescribing than during my first two years. There are some things that are a huge pain that I'm wondering are consistent at other programs (immediately staffing every patient specifically) or if it's less common.

Sorry for the dissertation, I'm just genuinely curious about what others' experiences have been, especially since I'm still pretty interested in academia after I finish residency.

Very similar setup for VA (CPRS), CMHC (cerner), and academic center (EPIC). Only difference is that the cmhc is more like 6-8 and the VA/academic center is like 10-12. "Elective" time is also spent in a specialty clinic 1/2 day per week, which could be LGBTQ clinic, student health, DBT group facilitator, women's wellness, neurointerventional, etc. 1/2 day per week in didactics.