Private practice for the high functioning cash paying patient

[BabyPsychDoc]

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Thanks to everyone for contributing to this post...

First of all, I will apologize for my comment regarding caring only for those who "contribute to our society."

What I was trying to convey is this...So, you are on call in a city hospital ER and homeless, drug seeking, manipulative patients continue to come through the door. They don't have jobs, have often served time in jail, many have committed crimes such as molesting children or abusing others and continue to cause problems out on the streets....Do they honestly contribute to our society.

Does the child molester really contribute to our society. I can't take care of those who sexually or physically abuse others, I just can't deal with. In my opinion, if someone has hurt a child then they have taken away from society and they would NEVER have an appointment with me.

I understand how all of you seem to act like you enjoy caring for everyone, even people I described above but honestly what do you value about the other parts of your life? Are you trying to reach out to receive internal gratification that you don't have in your personal lives? Just a thought because you all seemed to be so judgmental.

At the end of the day, this is a job and a practice is a business. Granted, it is a business of caring for patients which complicates things, but it's still a job. Any other profession would call the shots as I'm suggesting in a heartbeat.

Any patient I take on, I assure all of you I would do a great job, when I'm in the office and if the patient pays me. I'm not going to work for free though. And I'm not taking on patients that don't interest me, how would that be helpful to anyone?

Any other profession is allowed to do this....Lawyers carve out their specialties....corporate law, real estate, banking, etc...so why can't the medical profession.

I hate to break it to all of you, but the dermatologist who does mainly cosmetic work like botox, restylane, etc and asks for cash from wealthy parents to treat their children's acne....they are smart as hell. That is why the field is so competitive, because you can call the shots.

It doesn't make us evil physicians for being picky....it makes us smart business owners.

At the end of the day, I want to be home with my own family. I want my children to really know who I am. I want to be a good wife. I also would like to be a great physician, and this is why I have to limit my practice. Otherwise, I could not be the person I want to be to those who mean the most to me. Family and personal sanity comes first.

First of all...what does it mean to be a good wife? If it means keeping your house pristine and cooking dinner every night, making sure it is hot when your husband arrives home - then you are in a wrong profession. There are other ways of "being a good wife" - but you do not provide your definition. By the definition I provided above, I know I am a crappy wife. I am never home on time; my husband is the primary cook and housekeeping seems to be the logical thing to go when you are pressed for time. My husband knew the score before we got married, and we are making the best of what we have got.

However, my child does know who I am. He knows I am looking after sick people and he is proud of it. He also knows that my job affords us a reasonable lifestyle, and he is a mercenary.😀 My life is pretty much limited to my family and my work - when I am not at work, I am with my family. I think I am as good a mother as I could be, being a physician as well. SDN, The Economist and books are the only hobbies that I have at present - and they all have the convenience of being accessible at any time day or night. It is awesome that some of my colleagues do exciting things like sailing, mountaineering or playing golf - maybe, in a few yrs I will take up those hobbies, too, but at present I made my choice - I love my career and I love my family. And I do not have time for much else.

You are saying you want to be a "great physician". hate to disappoint you, but the greatest physicians history knows (or I know personally) have not been great family people. Being a physician is a job, but it is also a privilege - even when you treat "the homeless, drug abusing" ER frequent flyer. It is a privilege the society grants to you - and pays you for taking it up, too.

You will find it hard to do your job (whatever patient population you are working with), since your posts appear to be lacking any compassion and empathy towards patients. You make harsh judgements based on your subjective perception of the person's worth, completely forgetting the fact that you are who you are at present mostly as a result of complex interplay of social, psychological and economic factors from the moment of your conception. if you had been born to a crack teenage mother and abused by her drunkard boyfriend whe you were 6, there is little chance we would be having this particular discussion right now.

Yes, I guess I am "trying to reach out to receive internal gratification" - it is called altruism, you know. And I bow to DocSamson for putting it so succinctly in his post (I have never been so good with words...😳)

I once heard from a medical student that she chose to go to medicine because she "wanted a nice job, but did not want to be a lawyer". I thought that was the crassest remark I ever heard, until I read your posts.

 

[bananamed]

I hate to break it to all of you, but the dermatologist who does mainly cosmetic work like botox, restylane, etc and asks for cash from wealthy parents to treat their children's acne....they are smart as hell. That is why the field is so competitive, because you can call the shots.

I hate to break it to you but the dermatologist who does that isn't a dermatologist. I'd keep your generalizations to your field. If you get in.

 

[erg923]

Thanks to everyone for contributing to this post...

First of all, I will apologize for my comment regarding caring only for those who "contribute to our society."

What I was trying to convey is this...So, you are on call in a city hospital ER and homeless, drug seeking, manipulative patients continue to come through the door. They don't have jobs, have often served time in jail, many have committed crimes such as molesting children or abusing others and continue to cause problems out on the streets....Do they honestly contribute to our society.

This demonstrates a fundamentally poor understanding of the economic disparities and psychosocial forces that shape behavior in our society. This is is something every mental health worker needs to understand. People do not develop nor act in a vacuum. For goodness sake please take a community psychology and social psych class before you get out! Can you say "fundamental attribution error"?

I realize that the substance abuse population maybe frustrating to deal with at times, but I am appalled that you have such an uninformed and simple mind viewed of the concept and factors that contribute to substance abuse and addictions. Especially since you seem to be in a psychiatry residency! Do they really not teach anything about addiction psych in your program? Please do yourself and favor and start reading the literature in this area. This is a core competency for psychiatrists. because guess what? The anxious college female population have drug and alcohol problems too. Do you you know what the comorbidity of sub abuse is in the eating disorder pop? Moreover, judgment of worth has no baring on whether someone deserves your treatment. Personal preferences are one thing, but when you make yourself a judge of who deserves you, this is going to be transparent in your bedside manner and your interaction with all your patients.

Does a person "contribute to society?" Again, this a value judgment with no clear answer. I still don't know what this question means really. What is it? 40 hours/week and pays taxes? Or would you count something less tangible and material? Maybe the homeless guy who plays guitar on the street outside my apartment building. He contributes to my life....says hi to me every morning and makes me smile on my way out when the rest of society passes me by. See what I mean? Try asking the mothers of these people, maybe you will get a different and more human perspective on this question.

Lastly, I would beg to differ with your opinion of psychiatry. Psychiatry is psychiatry. It is not derm and it is not plastic surgery. All sub fields look for and require different personalities and different skills sets, so you comparison with other medical specialties is moot. Psych is different. Although, there is a large business component to practicing medicine, medicine itself should NOT be viewed as business. This cheapens the whole field, and undercuts the Hippocratic oath and the privilege of providing care to vulnerable populations. Wall street and investment banking is a "job." Medicine, although you dont have to make it your sole endeavor in life, is inherently a lifestyle. Most people certianly bestow it with a title of more than just any old "job." However, give your other views, I can understand why you would come to view medicine this way.

 

[kumar28]

first of all..u guys read WAY too much into certain comments. I guess one would expect that on a psych forum. The contribution to society comment was based on the fact that CERTAIN pts go out and use substances and then present themselves in the ER depressed and suicidal and we admit them and they are released after their simd. What a waste of time and money. Am i supposed to feel sorry for these substance users..hell no! They go out and get high and feel good and then subsequently crash. And then they do it again, and again, and again. And I am forced to work them up again, and again, and again...yipee! Are they, in this instance, contributing negatively to society by wasting tax payers money..hell ya!

Im not talking about intrinsic worth or whatever u guys are referring to...i dont know whats going on in these pts personal lives. Sure they may be good parents or whatever. Most of the time they are too low from the subsequent high to gather any information about their personal lives. All I know is what i see...and that is a total abuse of the system wasting alot of time and money by making poor judgements and getting high repeatedly. Sure there are those pts that do take ur advice and those pts are awesome because they are willing and eager to change their behaviors and u can reach out to them...but im not referring to those pts.

OPD..point taken about the diabetes pts however these pts have to actively control their sugars which sometimes takes much effort on their part. So sometimes their PASSIVITY can cause their sugars to be out of whack. Our SIMD pts have to actively seek out their drugs of choice and ACTIVELY choose to go out and get high..difference

And enough with the bashing of the OP. Shes just expressing her ideas and theres nothing wrong with that. Dont try to psychoanalyze her posts🙄. Medicine does have a business component and no need to act like a bunch of 'angels' saying otherwise. We wouldn't be doing what we do if we didn't get paid!

peace

 

[erg923]

.i dont know whats going on in these pts personal lives. Sure they may be good parents or whatever. Most of the time they are too low from the subsequent high to gather any information about their personal lives. All I know is what i see...

Then you are only looking at half the problem/issue, and subsequently, HALF THE PERSON. I'm not sure why you would devalue this part of your job. Psychopathology (including addiction) doesn't develop in a vacuum, ya know. "I know what i see" mentality is subject to a plethora of false impressions and biased conclusions. Apparently, as you admitted, there's alot going on you don't see.

I have been absolutely floored by the lack of knowledge of the psychosocial forces underlying substance abuse and addiction (or at the very least, ignoring them) by some residents on here.

PS: Are schizophrenics who stop the their meds immediately upon discharge and return a week later as deserving of your contempt? How about smokers for that matter? Are they not driving up health costs as well?

 

[OldPsychDoc]

first of all..u guys read WAY too much into certain comments. I guess one would expect that on a psych forum. The contribution to society comment was based on the fact that CERTAIN pts go out and use substances and then present themselves in the ER depressed and suicidal and we admit them and they are released after their simd. What a waste of time and money. Am i supposed to feel sorry for these substance users..hell no! They go out and get high and feel good and then subsequently crash. And then they do it again, and again, and again. And I am forced to work them up again, and again, and again...yipee! Are they, in this instance, contributing negatively to society by wasting tax payers money..hell ya!

Im not talking about intrinsic worth or whatever u guys are referring to...i dont know whats going on in these pts personal lives. Sure they may be good parents or whatever. Most of the time they are too low from the subsequent high to gather any information about their personal lives. All I know is what i see...and that is a total abuse of the system wasting alot of time and money by making poor judgements and getting high repeatedly. Sure there are those pts that do take ur advice and u can reach out to but im not referring to those pts.

OPD..point taken about the diabetes pts however these pts have to actively control their sugars which sometimes takes much effort on their part. So sometimes their PASSIVITY can cause their sugars to be out of whack. Our SIMD pts have to actively seek out their drugs of choice and ACTIVELY choose to go out and get high..difference

And enough with the bashing of the OP. Shes just expressing her ideas and theres nothing wrong with that. Dont try to psychoanalyze her posts🙄. Medicine does have a business component and stop acting like a bunch of 'angels' saying otherwise. We wouldn't be doing what we do if we didn't get paid!

peace

I stand by my indignation.

I'm not claiming angelic status, nor do I do my work for free. I work on an inpatient unit in an urban hospital, and I know how high my 30-day readmission rate is. I was also a resident once, and did plenty of seemingly futile readmissions of smoking COPDers and nacho-munching CHFers. Guess what--we chose to enter a profession where we have to deal with the damage people do to themselves and each other. If we limited the practice of medicine only to those "deserving" of treatment, I guess we'd all be neonatolgists specializing in genetic diseases.

Although I certainly understand your frustration with "frequent flyers" and the seemingly needless work they inconvenience you with, I do not think that it "reads too much into" your comments to extract that you might be defining the intrinsic worth of these inconvenient patients according to their net balance on the taxpayers' bottom line. And it would not surprise me to find that patients are subconsciously aware of your lack of respect for them as human beings, and as a result might be less likely to look to you for assistance.

Your comments also reveal what I believe to be a frank ignorance of addiction. I hope your residency program will have some modest success in teaching you that once a person becomes dependent on a substance, "actively choosing to go out and get high" is a progressively smaller contribution to the disease process. Perhaps once you have the opportunity to "know whats going on in these pts personal lives", you may gain some appreciation for the myriad ways in which their biological, social, and psychological predispositions combine to keep this process going. Perhaps if you can adopt the perspective that the taxpayer is paying YOU to do something about this problem, you will attempt to find out what happened between admission A and admission B and admission X to prevent them from achieving sobreity, and perhaps then you could posit yourself as part of the solution.
Did they have cravings? Perhaps you could learn about medications which can assist to reduce these.
Are their social networks completely devoid of sober people? Perhaps you could assist them to find a program where they can have sober supported housing for a few weeks to start the process of building a sober network.
Do they have a history of abuse, primitive coping skills, and serious family dysfunction? Perhaps you could start to build a therapeutic alliance that points them in the direction of the possibility of healthy human interactions.
Are they stuck in a cycle of poverty that you have been fortunate enough to escape in your life? Perhaps you could advocate more forcefully for policies which empower people to get help and become "contributors" to society.

Perhaps one day you will be privileged enough to pick and choose your patients and manage your business as you wish. For now, you are a resident (I presume, based on previous posts) and the job for which you are paid is to learn how to take care of difficult patients and how to practice your skills as a physician (so that if you are lucky the patients you want to see will want to come to you someday!). Dismissing an entire class of patients as "contributing negatively" is not one of the skills I encourage in my students and residents.

 

[billypilgrim37]

If we limited the practice of medicine only to those "deserving" of treatment, I guess we'd all be neonatolgists specializing in genetic diseases.

Or child psychiatrists 😉

If OPD had a choir, I'd be happy he was preaching at me.👍

 

[hippiedoc13]

If OPD had a choir, I'd be happy he was preaching at me.👍

Hallelujah. 👍 👍 👍

 

[hippiedoc13]

CERTAIN pts go out and use substances and then present themselves in the ER depressed and suicidal and we admit them and they are released after their simd. What a waste of time and money. Am i supposed to feel sorry for these substance users..hell no! They go out and get high and feel good and then subsequently crash. And then they do it again, and again, and again. And I am forced to work them up again, and again, and again...yipee! Are they, in this instance, contributing negatively to society by wasting tax payers money..hell ya!

Another way to look at this is that the way the current system is set-up is poorly designed to address this disorder. I think we can all agree that the cycle of ER visits and short, frequent readmissions for patients with substance-related disorders is often both counterproductive and wasteful of healthcare resources. However, the fact that the intervention you are employing is ineffective does NOT mean that there aren't other interventions which *are* effective, nor does it mean that those individuals who have the disorder are worthless non-contributors who don't deserve compassion or proper treatment for their disease process.

That's not to say that I haven't had my own moments of sheer frustration when evaluating patients in the ED who are suicidal in the context of intoxication or withdrawal. There have been times when I wanted to tear my hair out, I was so exasperated. To address kumar, I'm no angel (far from it!!), and I don't pretend to be.

A little distance and reflection on these incredibly frustrating encounters has helped me realize that (a) my anger is more appropriately directed at the crappy system which needs to direct our resources toward more effective interventions, and (b) a person who feels so crappy about his/her life that he/she comes to the ED, is in a LOT of pain. Fundamentally, that person is coming to us and asking for our HELP, because they are hurting. Badly. Perhaps they are asking for that help in a way that reflects poor insight and coping skills, but it's the only way they know how to ask.

Bottom line: if you feel (as I do) that the "frequent flyer model" is doing a poor job of addressing chronic relapsing psych disorders such as substance dependence and is a waste of society's resources, well then let's put our resources into more effective interventions that will actually help those with the disorder, and cut down on wasteful/counterproductive readmissions, instead of resenting the hell out of those who are already marginalized and suffering.

 

[BabyPsychDoc]

first of all..u guys read WAY too much into certain comments. I guess one would expect that on a psych forum. The contribution to society comment was based on the fact that CERTAIN pts go out and use substances and then present themselves in the ER depressed and suicidal and we admit them and they are released after their simd. What a waste of time and money. Am i supposed to feel sorry for these substance users..hell no! They go out and get high and feel good and then subsequently crash. And then they do it again, and again, and again. And I am forced to work them up again, and again, and again...yipee! Are they, in this instance, contributing negatively to society by wasting tax payers money..hell ya!

Im not talking about intrinsic worth or whatever u guys are referring to...i dont know whats going on in these pts personal lives. Sure they may be good parents or whatever. Most of the time they are too low from the subsequent high to gather any information about their personal lives. All I know is what i see...and that is a total abuse of the system wasting alot of time and money by making poor judgements and getting high repeatedly. Sure there are those pts that do take ur advice and u can reach out to but im not referring to those pts.

OPD..point taken about the diabetes pts however these pts have to actively control their sugars which sometimes takes much effort on their part. So sometimes their PASSIVITY can cause their sugars to be out of whack. Our SIMD pts have to actively seek out their drugs of choice and ACTIVELY choose to go out and get high..difference

And enough with the bashing of the OP. Shes just expressing her ideas and theres nothing wrong with that. Dont try to psychoanalyze her posts🙄. Medicine does have a business component and stop acting like a bunch of 'angels' saying otherwise. We wouldn't be doing what we do if we didn't get paid!

peace

Personally, I feel that the real waste of taxpayers' money that could be avoided are the zillions of HEALTHY multi-generational welfare parasites that could work but would not be bothered. If govt stopped paying people money for sitting on their arses for years at a time, we could actually have the resources necessary to address real issues, like mental illness (including addiction).

As far as your last comment - this is a free forum, and anyone is free to post anything they feel like: the OP is expressing her opinion, I am expressing mine - hell, you are expressing yours by telling me to shut up.🙄 Kind of goes with the territory...

Nothing more useful to add to the posters above. too late in the day.

good night😴

 

[Therapist4Chnge]

Personally, I feel that the real waste of taxpayers' money that could be avoided are the zillions of HEALTHY multi-generational welfare parasites that could work but would not be bothered. If govt stopped paying people money for sitting on their arses for years at a time, we could actually have the resources necessary to address real issues, like mental illness (including addiction).

I wish it were that easy. I have strong opinions about all social services (particularly those that continue to reward freq. flyers), but the research actually supports that the majority of people use the services as intended, and there is a % of people who abuse the heck out of it. A giant pet peeve of mine, but that is neither here nor there.

 

[billypilgrim37]

Let's be clear of context, the pinko John Edwardses of the United States run far to the right of the right-wing Margaret Thatchers of the UK.

These things, they do not compare. Entitlement programs in the United States, entitlement programs in the UK, these are different breeds of monkey.

 

[DrIng]

first of all..u guys read WAY too much into certain comments. I guess one would expect that on a psych forum. The contribution to society comment was based on the fact that CERTAIN pts go out and use substances and then present themselves in the ER depressed and suicidal and we admit them and they are released after their simd. What a waste of time and money. Am i supposed to feel sorry for these substance users..hell no! They go out and get high and feel good and then subsequently crash. And then they do it again, and again, and again. And I am forced to work them up again, and again, and again...yipee! Are they, in this instance, contributing negatively to society by wasting tax payers money..hell ya!

Medicine does have a business component and stop acting like a bunch of 'angels' saying otherwise. We wouldn't be doing what we do if we didn't get paid!

peace

Oh dear, You really don't get the whole concept of addiction do you....

As for "we wouldn't be doing what we do if we didn't get paid for it", when you've paced up and down the floor waiting for an acutely suicidal patient who has absconded form the ward to telephone you back on the basis of your relationship with them, you may have an understanding that while we wouldn't do this for free, no amount of amount compensates for that - we do it because we care about our patients and actually have a desire to help. And yes in case anyone is wondering the patient I'm referring is exactly the college educated depressed and anxious type the OP was referring to...

 

[BabyPsychDoc]

oh, don't get me started on the whole welfare issue. I could go on and on about it... Damage to the society in general and marriage institution in particular that the welfare reform of 1960s caused. Research showing that "back-to-work" reform of 1990s actually improved standard of living and life satisfaction among those affected by it, despite the public outcry "what about the children??!!" at the time. And I am talking about the US welfare here.

T4C, I would be interested in learning more about research that you refer to in your post. PM me some links, or post them here if you could, please - would be much appreciated.

Billy is right, UK welfare is quite a different story - much more generous, and much more inclusive (except "them damn ferners", who are not even able to claim a child tax credit lest they have their arses kicked out of the country - not that I am bitter or anything🙄).

In any system, my bottom line is - if you can work, you should. If you genuinely cannot due to an illness or disability, then the society must support you. However, simply being a single teenage mother (for example) is a poor excuse for staying home. Thatcher actually had an interesting idea of only supporting single teenage mothers if they agree to sign up for further education and skills training, with a view of enabling them to support themselves in a few years time. Unfortunately, such add-ons to her plan as mandatory Bible classes and communal living meant that was a non-starter, but the idea is right (pun intended) nonetheless. If you do not actively encourage adaptive behaviour, you effectively encourage maladaptive behaviour - and you end up with girls that discover that babies can become a source of income per se, and once one kid grows out of the "supported age", they produce another one. Hey-ho, who needs a job... Then the kids grow up with the understanding that this behaviour is the norm, and live their life with no aspirations or ambitions. Then they or their kids end up on the psych ward, because they had nothing better to spend their youth on than smoking pot and drinking alcohol on a daily basis from the age of 10. "Man hands on misery to man..." Then we see personality disordered, drug-addicted children of those children, and we all get very annoyed and frustrated with them, rushing to label them as "waste of taxpayers' money". We keep patching them up, detox-ing them and sending them off, fully aware that we are just barely keeping our heads above water without making much difference to lives of the people involved. In reality, we need to address wider social and economical issues, one of which is welfare, and the rest will inevitably follow.

PS. One of my favourite poems seems oddly appropriate with this post. So, I thought I would post the whole poem here:

"This Be the Verse

They **** you up, your mum and dad.
They may not mean to, but they do.
They fill you with the faults they had
And add some extra, just for you.

But they were ****ed up in their turn
By fools in old-style hats and coats,
Who half the time were soapy-stern
And half at one another's throats.

Man hands on misery to man.
It deepens like a coastal shelf.
Get out as early as you can,
And don't have any kids yourself.

Philip Larkin."

P.P.S. Billy, I have not got to the far right of the right-wing Thatcher, as yet. That is something to aspire to, though.😀

 

[Therapist4Chnge]

T4C, I would be interested in learning more about research that you refer to in your post. PM me some links, or post them here if you could, please - would be much appreciated.

The U.S. House of Representatives puts out a book/document on entitlement programs every 4-5 years (called "The Green Book"). A lot of the research is based off of these numbers/raw data.

Here is a link to the gov't website (http://aspe.hhs.gov/greenbook/), though I couldn't get the most recent link to work. You should be able to Google it....as many researchers reference the data. One thing to keep in mind is that data can be twisted, so try and read peer-reviewed/refereed journals, as they have a better shot of not being completely 1 sided.

 

[BabyPsychDoc]

The U.S. House of Representatives puts out a book/document on entitlement programs every 4-5 years (called "The Green Book"). A lot of the research is based off of these numbers/raw data.

Here is a link to the gov't website (http://aspe.hhs.gov/greenbook/), though I couldn't get the most recent link to work. You should be able to Google it....as many researchers reference the data. One thing to keep in mind is that data can be twisted, so try and read peer-reviewed/refereed journals, as they have a better shot of not being completely 1 sided.

Thank you - will check it out.

Not that I would put too much trust into a government source on this issue 🙄