Overbooked and overworked?

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cryhavoc

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So I came home and cried after clinic today. I can’t keep doing these 15 minute medicine appointments for people who need at least a half hour of supportive therapy. Absolutely none of the psychologists in my area have openings. I might have one or two stable people or med refills a day.

The rest are falling apart and have tried twenty medicines already and need a human to talk to. And I feel like all my attendings just don’t care, they just want to get out of here. So I’m efficient and I even get compliments on how efficient I am but in reality I feel like I am doing a disservice To all my patients to please my attendings.

Help or advice for an overworked and overbooked resident? I’m so burnt out and my patients deserve so much more than I have time to give…..

Also I almost lose it when they spend precious time pimping me or pretending to care about my education while overbooking me like crazy. Advice for that too please…..
 
Tell them exactly how you feel and take less patients, you definitely should not be overbooked and doing 15 minute visits in residency it should be a mix of 30 min and 1 hour visits for people who need more time
 
I agree, I have never been limited to 15 minute followups in any setting. I think 15 minute followups are only appropriate for very straightforward issues, such as a stable ADHD patient who basically just needs a medication refill. I'm sorry you are working in a setting like that. As robellis mentioned, in a resident clinic 60 minute intakes and 30 minute followups are pretty typical.

It sounds like you are in a situation where you may just have to do the best you can with what you have. Once you are out remember this experience. There are plenty of us within the field who don't believe the trend of shorter and shorter appointments (for example double-booking 15 minute "med check" clinics) is a good thing. You can choose to practice in settings that promote quality care, and advocate against this kind of erosion of our professional standards.
 
cryhavoc said:
Also I almost lose it when they spend precious time pimping me or pretending to care about my education while overbooking me like crazy.
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Who controls your schedule? Attendings or administrators?
If the former, is there some incentive for them to keep your appointments short and to overbook you? Do they get productivity bonuses or something?
 
Absolutely know your own boundaries. May sound too cushy, but in our residency we had 45 minutes for new patients (with additional 15 minutes to staff with attending). 30 minutes for follow up patients (with additional 10 minute to follow up). We all finished early which gave us time to do our notes.
 
“Each of us was becoming more isolated. The more we needed support, the more shallow were our friendships; the more we needed sincerity, the more sarcastic we became. It had become an unwritten law among the terns: don’t tell what you feel, ’cause if you show a crack, you’ll shatter. We imagined that our feelings could ruin us, like the great silent film stars had been ruined by sound.”
 
cryhavoc said:
So I came home and cried after clinic today. I can’t keep doing these 15 minute medicine appointments for people who need at least a half hour of supportive therapy. Absolutely none of the psychologists in my area have openings. I might have one or two stable people or med refills a day.

The rest are falling apart and have tried twenty medicines already and need a human to talk to. And I feel like all my attendings just don’t care, they just want to get out of here. So I’m efficient and I even get compliments on how efficient I am but in reality I feel like I am doing a disservice To all my patients to please my attendings.

Help or advice for an overworked and overbooked resident? I’m so burnt out and my patients deserve so much more than I have time to give…..

Also I almost lose it when they spend precious time pimping me or pretending to care about my education while overbooking me like crazy. Advice for that too please…..
Click to expand...
At least you are getting a taste of what it's like after your residency is complete. Corporate usually books six an hour as they think there will be cancellations.
 
We don't know the dynamics of this program...
Best advice may be to keep your head down, do what you can and finish residency - don't rock the boat.
Staffing may be a true 30 minute appointment, but the resident gets 15-20min, and the remaining 10min is staffing time with the attending. Charting happens after clinic.

I'm in private practice with so much more control over everything. But even with that, one insurance company, of patients that were about 15-20% of my panel, very few therapists took this insurance, even before covid, and with covid, basically no one. Similar to you, patients need therapy, but can't get them in anywhere. I chose not to internalize the failures of this very large insurance company to pay people more to want to be paneled with them, and I dropped this company. I'm so much happier not working with that insurance company anymore and dealing with these road blocks. Not my problem to fix.

So, do what you can, which is basically a quick med check. You are owned by your residency and if that's how they want it, so be it. Be sure to document patients needs for therapy, provided referrals, options that include in network, out of network therapists, discussion of IOP/PHP groups, cash based therapy options, and even free NAMI groups. Online CBT. Homework workbooks, etc. Do what you can, document patient response, and move on.

You can't be the savior for everyone nor should you. The faster you learn this, the easier it is in the future. But you can help point people to resources, their full options, even if the confines of real world logistics shoot down these plans.

Write down the details of what you don't like about your residency clinic, and in the future reference these notes so you know what to avoid in future job prospects.
 
Intensive outpatient programs! Also...remember that being a resident is not like being an attending. You do get more control!
 
Heist said:
More control as an attending? Bwhahah
Click to expand...

I definitely have more control. I get to choose when I work, how much I work and how long I see my patients for. If I wanna do family therapy with parents for a kid for an hour, I can do it. If I want to see a patient for weekly psychotherapy, I just schedule them in my schedule. I get 30 minutes with all my followups and 60 minutes for all my new at a minimum (60+30 for my child patients). If I don't want to see a certain age or diagnosis or take referrals from a certain person, I just tell my intake. If I want to limit myself to a certain number of new patients a day, I just tell my intake. If I don't work, I don't make money. If I want to make more money, I just open up more available hours to work more.

Instead of being jaded about it, go make a change for yourself. This doesn't give residents any hope they can have a better time after residency.

OP if you're getting 15 minutes total for patients that's very tight. The tightest we had was 20 minute followups at a CMHC with indirect supervision, so you didn't have to staff cases until the end of the day. More typical was 30 minute followups with direct supervision (so maybe 20ish minutes per patient with 3-5 minutes to staff and 3-5 minutes for the attending to say hi to the patient). In my outpatient child clinic, we had 30min followups with supervision just once a week, so truly 30min followups.

You certainly shouldn't be seeing truly 15 minute back to back to back followups as a resident...there's sure to be pretty much no learning going on with that besides how to be ultra efficient in clinic. What kind of clinic is this? Is this a clinic where it's going to be a problem if you talk to your PD about the lack of learning you're feeling you're getting from the clinic? Often framing things as being concerned about the "lack of learning/education" going on with particular rotations/clinics is the weasel word to try to get things changed, cause they don't want this kind of stuff coming back on ACGME surveys (ACGME has been coming down hard on places lately).
 
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cryhavoc said:
So I came home and cried after clinic today. I can’t keep doing these 15 minute medicine appointments for people who need at least a half hour of supportive therapy. Absolutely none of the psychologists in my area have openings. I might have one or two stable people or med refills a day.

The rest are falling apart and have tried twenty medicines already and need a human to talk to. And I feel like all my attendings just don’t care, they just want to get out of here. So I’m efficient and I even get compliments on how efficient I am but in reality I feel like I am doing a disservice To all my patients to please my attendings.

Help or advice for an overworked and overbooked resident? I’m so burnt out and my patients deserve so much more than I have time to give…..

Also I almost lose it when they spend precious time pimping me or pretending to care about my education while overbooking me like crazy. Advice for that too please…..
Click to expand...
Also be glad you are a resident now. The hours for residency are much easier now.
 
Heist said:
My friends at hospitals tell me they don't have much control as attendings.
Click to expand...
sure, but as an attending you can choose where you work and don't have to be employed. As a resident, you have almost no choice.

I am very fortunate, but I am employed and I control my schedule completely. Not a single patient is scheduled without my say so. I have a half day blocked off to see a single new patient (typically 120-150min appt with rest of time for extensive chart review, coordination of care, and documentation) and that counts as a full clinic. Or 3-4 follow ups (typically 45-60mins) for a half-day. I usually don't see patients less frequently than every other week and typically see patients for weekly or twice weekly therapy. Once they no longer need me, I discharge them from my care. I don't see patients before 10am. The physicians I work with are very appreciate of my expertise, and I work with awesome, grateful, motivated patients who get better. The work is very intellectually stimulating with high complexity patients. I negotiated my schedule and have everything in writing. It's basically like I have a private practice, but in a specialist tertiary care clinic and with the crappy academic salary (though which private hospital or group practice would pay me the same for the comparatively low volume?) Though I have several revenue streams so I still come out on top.
 
Heist said:
The bean counters at the top are all about making those rvus.
Click to expand...

Have you considered that your job just sucks? It doesn't sound like you're super happy at it. If you are indeed a board eligible/certified psychiatrist you should have no problems finding a better gig.
 
cryhavoc said:
So I came home and cried after clinic today. I can’t keep doing these 15 minute medicine appointments for people who need at least a half hour of supportive therapy. Absolutely none of the psychologists in my area have openings. I might have one or two stable people or med refills a day.

The rest are falling apart and have tried twenty medicines already and need a human to talk to. And I feel like all my attendings just don’t care, they just want to get out of here. So I’m efficient and I even get compliments on how efficient I am but in reality I feel like I am doing a disservice To all my patients to please my attendings.

Help or advice for an overworked and overbooked resident? I’m so burnt out and my patients deserve so much more than I have time to give…..

Also I almost lose it when they spend precious time pimping me or pretending to care about my education while overbooking me like crazy. Advice for that too please…..
Click to expand...

How many patients are you seeing on average in a typical clinic day? New patients/follow ups?

Suggestion One:
1. Improve efficiency. Depending on the EMR, I prewrite all my notes when I get there, and make changes during the visit. If a no show, can put the note as an error or delete it typically.
2. Review the chart before you see the patient; already have a plan in mind for what you want to do with the patient; proceed to ask questions that either verify your plan is correct or verify that it needs some sort of change.

Suggestion Two:
1. Detach emotionally a bit. We are limited as to what we can do sometimes. Im an attending at one of the biggest facilities in the region and primarily treat the underserved/economically disadvantaged with few resources. Know how you can help them and how you can't. It is not your fault that you cant always save them, but perhaps you can help make it somewhat less unplesant for the patient, their experience. Some people cant be cured or fixed but they can be helped.

Suggestion Three:
1. Talk to them. Why are they pimping you during encounters? There needs to be a set supervision time where they pimp you if they really want to but not while seeing patients. When I was in residency I would staff all my patients for the week during one supervision time period, and I would never staff the same day (unless medicare/medicaid due to billing).

Your goal isnt always to cure patients so to speak, but to help improve quality of life. But there are always limits to this. Know that you do your best and take some solace in that.

When I was in residency there were residents who would routinely go home late because they would set some impossible standard on themself. I would never leave late but I always kept myself grounded with logical expectations of what I could and could not do, I did not try to write essay notes (kept it simple with only peritent information), and I was prepared for each encounter by doing a chart review before seeing them and looking for certain details.
 
Also, FYI you always have control as a psychiatry attending. Know why? Because the demand is huge and the supply is low. In my state, midlevels cant practice without physician supervision, so even though theres a lot of midlevels here, I am the one that ultimately signs off.

If you feel you don't have control, you have the power to leave. And in most cases, they cant just easily replace you. When they realize their income stream or physician signer might leave them, the scrambling will start. The high ups dont want disruptions to the status quo.
 
My experience in clinic as a resident was similar. It was a very silly clinic with people with substantial psychosocial issues, personality pathology, and severe illness that were really more appropriate for a public CMHC with appropriate staffing, especially case management services. There was very little that could be done to work on many of their issues, and certainly pharmacotherapy was not a central role of that plan.

A couple of thoughts. First, I agree with other posts that have suggested trying not to internalize the failings of a system. You are not superman and you cannot be everyone for every patient. You do the best that you can, and as long as you can honestly tell yourself that you've done the best that you can given the very real constraints that you have, what more can you possibly do? Second, remember that, for many patients, simply having someone to talk to - even if its every 3 months - is very valuable and therapeutic to them. If the appointments really were as pointless and useless as you seem to suggest, do you think the patients would still come?

How you want to approach this is up to you. On the one hand, I don't think it's unreasonable to bring up your concerns with either the clinic attendings or your program. On the other hand, I doubt there is much that's going to be done acutely.
 
Heist said:
My friends at hospitals tell me they don't have much control as attendings.
Click to expand...
Heist said:
Also be glad you are a resident now. The hours for residency are much easier now.
Click to expand...
Heist, not to be invalidating in any way, but I wonder if your job might be a couple of standard deviations worse than your "average" psychiatrist job. Almost universally people find being an attending to have more autonomy, respect, and better workload. Sure you have greater responsibility, but if your overall experience was better as a resident, then you either went to a super cush/supportive residency, or your current job sucks and your employer is taking you for a ride.
clausewitz2 said:
Have you considered that your job just sucks? It doesn't sound like you're super happy at it. If you are indeed a board eligible/certified psychiatrist you should have no problems finding a better gig.
Click to expand...
I completely agree!
 
NickNaylor said:
How you want to approach this is up to you. On the one hand, I don't think it's unreasonable to bring up your concerns with either the clinic attendings or your program. On the other hand, I doubt there is much that's going to be done acutely.
Click to expand...

No one thinks that structuring a clinic this way is optimal from a providing quality care perspective, so I agree that raising your concerns is most likely not to change anything. It's not like, "wait, you mean 15 minutes isn't a good time for follow-ups? Our bad." Depending on the setting though I can perhaps imagine your residency training folks are not aware of how bad this particular site is and might be able to exert some pressure for improvement if you bring them your concerns.
 
clausewitz2 said:
No one thinks that structuring a clinic this way is optimal from a providing quality care perspective, so I agree that raising your concerns is most likely not to change anything. It's not like, "wait, you mean 15 minutes isn't a good time for follow-ups? Our bad." Depending on the setting though I can perhaps imagine your residency training folks are not aware of how bad this particular site is and might be able to exert some pressure for improvement if you bring them your concerns.
Click to expand...

Yup, completely agree. Program administration/leadership can be surprisingly out-of-touch with what's going on at individual training sites and really only get a good pulse of what's going on by hearing from residents. That was the case in my program at least.
 
splik said:
sure, but as an attending you can choose where you work and don't have to be employed. As a resident, you have almost no choice.

I am very fortunate, but I am employed and I control my schedule completely. Not a single patient is scheduled without my say so. I have a half day blocked off to see a single new patient (typically 120-150min appt with rest of time for extensive chart review, coordination of care, and documentation) and that counts as a full clinic. Or 3-4 follow ups (typically 45-60mins) for a half-day. I usually don't see patients less frequently than every other week and typically see patients for weekly or twice weekly therapy. Once they no longer need me, I discharge them from my care. I don't see patients before 10am. The physicians I work with are very appreciate of my expertise, and I work with awesome, grateful, motivated patients who get better. The work is very intellectually stimulating with high complexity patients. I negotiated my schedule and have everything in writing. It's basically like I have a private practice, but in a specialist tertiary care clinic and with the crappy academic salary (though which private hospital or group practice would pay me the same for the comparatively low volume?) Though I have several revenue streams so I still come out on top.
Click to expand...
When I worked at a hospital and tried to discharge a patient they wouldn't let me as the patient was too valuable to the health system. A social worker was my "boss".
 
At both of the places I see patients, I have 30 minutes for follow-ups and 1 hour for new patients. For my forensic work, there are no limits. Rarely do I have an evaluation that is under 2-3 hours.
 
calvnandhobbs68 said:
I definitely have more control. I get to choose when I work, how much I work and how long I see my patients for. If I wanna do family therapy with parents for a kid for an hour, I can do it. If I want to see a patient for weekly psychotherapy, I just schedule them in my schedule. I get 30 minutes with all my followups and 60 minutes for all my new at a minimum (60+30 for my child patients). If I don't want to see a certain age or diagnosis or take referrals from a certain person, I just tell my intake. If I want to limit myself to a certain number of new patients a day, I just tell my intake. If I don't work, I don't make money. If I want to make more money, I just open up more available hours to work more.

Instead of being jaded about it, go make a change for yourself. This doesn't give residents any hope they can have a better time after residency.

OP if you're getting 15 minutes total for patients that's very tight. The tightest we had was 20 minute followups at a CMHC with indirect supervision, so you didn't have to staff cases until the end of the day. More typical was 30 minute followups with direct supervision (so maybe 20ish minutes per patient with 3-5 minutes to staff and 3-5 minutes for the attending to say hi to the patient). In my outpatient child clinic, we had 30min followups with supervision just once a week, so truly 30min followups.

You certainly shouldn't be seeing truly 15 minute back to back to back followups as a resident...there's sure to be pretty much no learning going on with that besides how to be ultra efficient in clinic. What kind of clinic is this? Is this a clinic where it's going to be a problem if you talk to your PD about the lack of learning you're feeling you're getting from the clinic? Often framing things as being concerned about the "lack of learning/education" going on with particular rotations/clinics is the weasel word to try to get things changed, cause they don't want this kind of stuff coming back on ACGME surveys (ACGME has been coming down hard on places lately).
Click to expand...
Same. I'm employed but still have much more control than in residency.
 
How anyone could think that you have less control as an attending compared to a resident is beyond me, it’s not even close, as an attending it’s your license on the line so you must have all the control, if you feel something is inadequate or inappropriate you simply do not do it, if they don’t like it they are free to fire you and take a year to replace you
 
splik said:
I am very fortunate, but I am employed and I control my schedule completely.
Click to expand...
Fortunate but also professional and calculating. I run low on empathy for physicians in practice who complain about their poor treatment and lack of control. There are always choices although it generally comes down to poor negotiation, lack of business knowledge, unwilling to change geographic locations etc.
 
How much control do you have over clinic scheduling?

My clinic had a similar arrangement which was also waayyy less than ideal. But I learned early in the year that I actually had control over my clinic schedule as long as my patient panel was well attended to. After figuring that out, I started pushing stable patients out as far as possible, then using the open time slots to book patients for two time slots to provide supportive or problem-focused therapies. It definitely felt like a cheat code when I figured that out and quality of care went up a lot.
 
Why are your attendings forcing 15 minute visits? That’s so dumb how the hell can a resident learn and provide good care in 15 minutes? That’s definitely not possible
 
cryhavoc said:
So I came home and cried after clinic today. I can’t keep doing these 15 minute medicine appointments for people who need at least a half hour of supportive therapy. Absolutely none of the psychologists in my area have openings. I might have one or two stable people or med refills a day.

The rest are falling apart and have tried twenty medicines already and need a human to talk to.
Click to expand...
You need to understand your role in the poopy system and fully accept your boundaries within it. We don't unilaterally and immediately impact patients like other specialties. We don't push tPA, remove cataracts, replace knees etc. We no longer have the power to immediately change patients' lives by locking them in asylums for years, forcing them to take powerful meds, making them exercise by tending the grounds, and requiring them to engage in therapy. We merely render opinions in exchange for cash.

Understand these "falling apart" patients are actually stable, to the extent there is any actual stability in the universe. It's highly probable their lives will be chronically chaotic, in a steady slow controlled decline, until the day they die. Whether 1 week or 10 years, whether they see you or Freud or Stahl or Beck or no one, their outcome is likely the same. You can leave then return in 10 years, and these patients will likely discuss the same 5 problems they had at their last session with you, albeit more obese, with more lipsmacking, and more shopworn from their lifestyle choices. But for the iatrogenic stuff, these patients in reality are like the average American (except for the alcohol and opioid patients, they have higher mortality rates).

Also, stop lying to patients and yourself. That patient who has tried "20 meds" will neither be helped by you prescribing another med, nor having the world's best psychologist on board. Unless they want to.
 
robellis said:
How anyone could think that you have less control as an attending compared to a resident is beyond me, it’s not even close, as an attending it’s your license on the line so you must have all the control, if you feel something is inadequate or inappropriate you simply do not do it, if they don’t like it they are free to fire you and take a year to replace you
Click to expand...
If you are working for a hospital, your privileges could be revoked, which would cause severe career problems.
You can not simply "not do it ", even if it's a hospital outpatient department
 
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michaelrack said:
If you are working for a hospital, your privileges could be revoked, which would cause severe career problems.
You can not simply "not do it ", even if it's a hospital outpatient department
Click to expand...
Wasn’t there a surgeon who was literally killing patients and it took years for his privileges to be revoked? I think we’ll be fine for standing up for proper care
 
michaelrack said:
If you are working for a hospital, your privileges could be revoked, which would cause severe career problems.
You can not simply "not do it ", even if it's a hospital outpatient department
Click to expand...
Beyond being punitive, I'd be surprised to hear a hospital taking steps to revoke privileges related to clinical decision-making absent gross malpractice or mismanagement, in which case you'd likely already be in trouble with other entities.
 
NickNaylor said:
Beyond being punitive, I'd be surprised to hear a hospital taking steps to revoke privileges related to clinical decision-making absent gross malpractice or mismanagement, in which case you'd likely already be in trouble with other entities.
Click to expand...
I wasn't talking about clinical decision making, but I guess that's what every one else was
 
Most people have commented on the situation, but a few more specific things to think about:

cryhavoc said:
I can’t keep doing these 15 minute medicine appointments for people who need at least a half hour of supportive therapy.
Click to expand...

That's bad even in PP as an attending. Sounds like this setup is meant to be checking for safety/stability level, prescribing, and scheduling f/up. I'm sorry you're dealing with this, but I'd get your whole class/program together and let staff know how inappropriate this is. I'd also report it in the annual survey.


cryhavoc said:
Absolutely none of the psychologists in my area have openings.
Click to expand...

This fairly common. It's hard to find good therapy in most places, but if it's mostly supportive therapy you want these patients to have, even most LMSWs should have adequate skills to provide your patients some benefit.


cryhavoc said:
I might have one or two stable people or med refills a day.
Click to expand...

Sounds like a fairly typical CMHC population. This is the unfortunate reality of care for many populations.


cryhavoc said:
The rest are falling apart and have tried twenty medicines already and need a human to talk to. And I feel like all my attendings just don’t care, they just want to get out of here. So I’m efficient and I even get compliments on how efficient I am but in reality I feel like I am doing a disservice To all my patients to please my attendings.
Click to expand...

It may be that your attendings do care but feel their role is to provide the correct medications which may require little time for appointments. They may also hate the system as much as you do. If the patients have tried 20 meds and they didn't help, then you're probably right that they need therapy. In that case, I'd ask if medications are appropriate at all for those patients and if they're not figure out what would actually be beneficial. If you really feel like you're not helping, be straightforward with these patients and tell them that, it may clear your schedule a bit so you do have time to spend with the people who you can actually help.
 
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