Practice Environment and Values

[sloop]

I have recently been struggling with what I believe to be a fairly deep disconnect with the culture of my institution when it comes to values, and I am wondering if others have experienced the same or have advice.

Admittedly, I can sometimes be a bit idealistic. I truly went into medicine because I want to help people, and I believe that one of the amazing things about being a doctor is the obligation to overcome biases to provide high quality care to everyone. I work with a correctional population and I take pride in treating people with dignity and respect no matter what they have done in the past. I genuinely enjoy the actual work I do. Unfortunately, I find that there is a pervasive culture where people think it is acceptable to just phone it in, don’t really care about the patients, and view patients in disparaging ways (“they’re just criminals” etc.). Many of the physicians seem to share this same attitude. They view their job as simply moving patients around rather than really treating them. This has also infected forensic practice, where several evaluators seem to basically form whatever opinion is most expeditious for the hospital, and there sometimes seems to be some expectation that evaluators will do this.

I am pretty disgusted by it. On some level I can just silo myself off on my unit and continue to do my work according to my standards, but I can’t fully escape hearing these attitudes and they infuriate me. I am conflicted, though, because overall the job is good. I make what I consider reasonable money for the amount of time I have to put in. I get to treat really sick patients, which I find gratifying. I get to work with residents and try to give them a good forensic experience. There is also a group of people I consider competent and ethical, and I consider them good friends. I also feel an obligation to advocate for the patients. Still, it is just exhausting to be fighting this moral battle every day.

Is this a grass is greener situation? Is this a struggle everywhere? Does anybody have any tips to make it more bearable?

---

Members don't see this ad.

 

[lobstar]

If you value an intellectual environment, it makes sense to start looking around at least. The culture is the culture and it's certainly not the same everywhere. I'm not forensics but I've seen it with other areas within general practice.

I've talked to a wise mentor about similar things. The average psychiatrist is, well, average. I think as doctors we sometimes have higher expectations that people can't meet. Half of all psychiatrists are below average at psychiatry compared to other psychiatrists.

People take shortcuts and choose the path of least resistance all the time because they're people. We all do it sometimes. I've seen attendings fear lawsuits shortly before retirement just start involuntarily keeping patients who don't need it, one didn't know what atomoxetine was, some never learn the EMR, etc. I'm sure some will skip learning about cobenfy and whatever else.

Gotta keep your own standards and if your environment is poor, look elsewhere. Just be calculated about it, because like you said the grass might not be greener.

 

[comp1]

To some extent, yes, the grass is greener feeling is a universal experience and you will feel it in any job. However...you're in corrections. What exactly drew you to corrections and to this job in particular to begin with? You can work with residents and treat very sick patients in a heck of a lot of other places. In my experience, corrections is one of the absolute most mercenary places for physicians to work. If you are indeed making "reasonable money" in corrections work or forensic consultations, you're likely being significantly underpaid and that could explain your colleagues.

 

[Sushirolls]

It is going to persist in all practice environments.

I'm in out patient private practice in middle of nowhere. Essentially FM country, and the FM just don't refer. When I do see people trickling in from referrals or by patient initiative its often these thoughts: I wish they came in sooner. These meds are a mess. These Dx are a mess. And the ARNPs are the worst offenders, they truly don't know what they don't know. Insurance has its input in the cesspool, too.

I left different environment several years ago and my current situation is far better, but still has scat.

You have the power to reduce the scat, and choose the type - but you can't get rid of it.

 

[Merovinge]

MD owned/lead organizations and groups are your best bet. They can vary from academics to large practices to small practices and even across most levels of care. I was speaking to a prospective applicant recently who has worked at several different organizations and she noted how rapidly and palpably the difference is between places that are run by MDs vs MBAs or therapists.

 

[Celexa]

You cant get away from it entirely but if its correct as mentioned above you're in corrections, it seems unlikely you're going to find another job in the same area with a higher proportion of people giving a ****. If you leave for another gig, academics is good for increasing the proportion of people who give a **** (its never 100%, and some of the people who give a **** are still on the wrong part of the dunning kruger curve) but will pay you a lot less. Quite possibly a full order of magnitude less.

There is no perfect job. It very much depends on your personal priorities.

 

[FlowRate]

MD owned/lead organizations and groups are your best bet. They can vary from academics to large practices to small practices and even across most levels of care. I was speaking to a prospective applicant recently who has worked at several different organizations and she noted how rapidly and palpably the difference is between places that are run by MDs vs MBAs or therapists.

Second this. Despite what someone was saying about KP in a different thread, I have to say the overall quality of care our physicians provide is very high. There will always be a spectrum of clinical quality, but we try really hard to hire solid docs.

 

[Stagg737]

Admittedly, I can sometimes be a bit idealistic. I truly went into medicine because I want to help people, and I believe that one of the amazing things about being a doctor is the obligation to overcome biases to provide high quality care to everyone. I work with a correctional population and I take pride in treating people with dignity and respect no matter what they have done in the past. I genuinely enjoy the actual work I do. Unfortunately, I find that there is a pervasive culture where people think it is acceptable to just phone it in, don’t really care about the patients, and view patients in disparaging ways (“they’re just criminals” etc.). Many of the physicians seem to share this same attitude. They view their job as simply moving patients around rather than really treating them. This has also infected forensic practice, where several evaluators seem to basically form whatever opinion is most expeditious for the hospital, and there sometimes seems to be some expectation that evaluators will do this.

So it sounds like there's potentially two separate but significant problems here. The first is what others have addressed in that you feel people are just skating by doing the bare minimum and providing sub-standard care to a vulnerable population. While this is certainly something that happens in many places, there are also plenty of places that aren't like this where the docs provide solid care and actually give a crap about what they're doing. Not a "grass is greener" situation and I'm sure you can find places that are better than where you're at if it's really that bad.

The second point which I haven't seen people comment on which you kind of allude to is a difference in values and possibly morals. Idk your actual patient population, but many people would say that some prisoners are legitimately awful human beings (or monsters and not humans) who have earned their punishment and don't deserve high levels of care. I wonder how much of these attitudes from some co-workers comes from working with individuals who have done truly horrendous things where the co-worker's counter-transference to some patient is generalized to all patients through burnout or lack of self-monitoring. Regardless, the idea that you are going to be able to find a work setting (especially a larger organization) where everyone shares all or even most of your values is much more of a "greener grass" situation. This is especially relevant when you're talking about the attitudes or morals of individuals in roles that may be very different from your own as a psychiatrist (techs and nurses who are front line for physical assaults).

 

[comp1]

The above post is very true and something I hadn't thought of. The OP's own (positive?) countertransference might be some of the problem here. Hopefully they are working through it in some manner. But yes, you're not going to find any job anywhere where everyone working there thinks every patient is deserving of the same level of treatment. They might attempt to do it because it's the job, but they aren't going to believe it. It's just not going to happen, whether that's right or wrong.

 

[sloop]

To some extent, yes, the grass is greener feeling is a universal experience and you will feel it in any job. However...you're in corrections. What exactly drew you to corrections and to this job in particular to begin with? You can work with residents and treat very sick patients in a heck of a lot of other places. In my experience, corrections is one of the absolute most mercenary places for physicians to work. If you are indeed making "reasonable money" in corrections work or forensic consultations, you're likely being significantly underpaid and that could explain your colleagues.

So it sounds like there's potentially two separate but significant problems here. The first is what others have addressed in that you feel people are just skating by doing the bare minimum and providing sub-standard care to a vulnerable population. While this is certainly something that happens in many places, there are also plenty of places that aren't like this where the docs provide solid care and actually give a crap about what they're doing. Not a "grass is greener" situation and I'm sure you can find places that are better than where you're at if it's really that bad.

The second point which I haven't seen people comment on which you kind of allude to is a difference in values and possibly morals. Idk your actual patient population, but many people would say that some prisoners are legitimately awful human beings (or monsters and not humans) who have earned their punishment and don't deserve high levels of care. I wonder how much of these attitudes from some co-workers comes from working with individuals who have done truly horrendous things where the co-worker's counter-transference to some patient is generalized to all patients through burnout or lack of self-monitoring. Regardless, the idea that you are going to be able to find a work setting (especially a larger organization) where everyone shares all or even most of your values is much more of a "greener grass" situation. This is especially relevant when you're talking about the attitudes or morals of individuals in roles that may be very different from your own as a psychiatrist (techs and nurses who are front line for physical assaults).

To answer some of the questions, I work for a state forensic hospital treating people who are incompetent to stand trial and not guilty by reason of insanity. I also do some forensic evaluations for defendants on other wards. I do not work in a jail. What drew me to work here was the ability to work in a treatment role in a forensic environment while also doing evaluations occasionally. This is really the only forensic hospital in my area, so it would effectively be impossible to do this type of work outside of this institution. When I can silo myself off, I really do enjoy the work. I make about $310K for M-F business hours, no call, pension plan, etc. Not amazing money, but not atrociously unfair for the amount of work involved in my opinion.

Honestly it is less incompetent or lazy care that infuriates me (although that happens too) but more the negative, at times dehumanizing, attitudes of staff.

 

[sloop]

The above post is very true and something I hadn't thought of. The OP's own (positive?) countertransference might be some of the problem here. Hopefully they are working through it in some manner. But yes, you're not going to find any job anywhere where everyone working there thinks every patient is deserving of the same level of treatment. They might attempt to do it because it's the job, but they aren't going to believe it. It's just not going to happen, whether that's right or wrong.

I don’t think this is a countertransference issue, at least on my end. I am endlessly frustrated by many of my patients. Many of them have severe personality disorders. Many of them don’t want to take medication and force me to go to court. I just think that part of being a doctor is overcoming your personal feelings and finding a way to provide good care and treat everyone with a baseline level of respect.

 

[FatherPsychiatry]

To answer some of the questions, I work for a state forensic hospital treating people who are incompetent to stand trial and not guilty by reason of insanity. I also do some forensic evaluations for defendants on other wards. I do not work in a jail. What drew me to work here was the ability to work in a treatment role in a forensic environment while also doing evaluations occasionally. This is really the only forensic hospital in my area, so it would effectively be impossible to do this type of work outside of this institution. When I can silo myself off, I really do enjoy the work. I make about $310K for M-F business hours, no call, pension plan, etc. Not amazing money, but not atrociously unfair for the amount of work involved in my opinion.

Honestly it is less incompetent or lazy care that infuriates me (although that happens too) but more the negative, at times dehumanizing, attitudes of staff.

This is my experience as well - I work in a jail, and regularly have people returning from state hospitals. I've been here enough years where I've probably seen discharge paperwork from many, if not most of the psychiatrists who treated these patients (if you're in California, I'm talking about people coming back from Patton or Metropolitan State Hospital). There is definitely a huge difference between psychiatrists and I'm starting to get a feel which ones actively managed a patient and tried to get them competent quickly, and who just "phoned it in" and kept a rock on their unit for as long as they could, up Zyprexa 5mg every 3mo, to make life easy.

That variance in psychiatrists is true here in the jail as well.

I think what attracts people to these jobs is the work-life balance/pay that you alluded to, so (especially given how desperate most of these places are for psychiatrists) you're gonna pick up a lot of psychiatrists that focus entirely on that, and patient care is far lower on their list of priorities, behind fiddling with their crypto, real estate, escape to the gym, etc. Maybe academia, with lower pay and less work-life balance, attracts people who prioritize other things, but those other things might not be patient care; could be climbing the ladder, research etc.

I do enjoy trying to a good job, as basic as that sounds, and accepting that's all I can really do. For me, that means spending a little more time digging through the chart history and sometimes spending more time with the patient, to find out what they really need. I could spend less time doing that, and more time on SDN/Substack/going for walks, but... eh I could use some Stoic "living according to one's nature" type quote to throw down here.

Hope things work out for you.