Pros/cons of training in different inpatient settings

[slowthai]

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I'm an incoming psych resident wondering what the pros/cons of training in different inpatient settings (private, community, state, VA, etc) are.

 

[comp1]

Oh such a great question! So there's going to be a great deal of variety. It's interesting that you get a choice in where you rotate as a resident. Ideally, you should see all of these sites. I'm, of course, highly biased towards VA. Starting with the best...the VA has a lot of resources. You're going to get comfortable with a relatively homogenous patient population and how to treat them. Illnesses are generally less severe than other hospitals and you aren't going to be pressured to discharge people early or ever consider financial aspects in general. Attendings are rarely overworked and generally have a lot of time for teaching. The big con is malingering. It's severe and will be an issue most days because the potential benefits of disability are significant (more money than you will make as a resident counting taxes). That said, while it can be draining, malingering and factitious disorder management is a critical skill to develop as a resident and the VA can be a great way to master it. It can be much more subtle than at other sites. Also, you do get to (occasionally) treat an honest to goodness war hero, which is really cool.

I spent the bulk of my inpatient time in residency in a county Medicaid psych unit which I'm guessing is what you meant by community. It's rough. The patients are extremely sick and the resources are extremely limited. You'll discharge a chunk of people to the street with just $200 in general assistance. You'll really get down deep into why the homeless problem exists in the US at a granular level. On site violence is a pretty common concern, although gun ownership is obviously less than at the VA and thus post discharge concerns of violence are sometimes a bit less. County psych also has a very limited formulary in my experience. You'll get familiar with Target's $10 generic list. It can be soul crushing, but it's where to see the sickest of the sick. Diagnoses are not challenging, but sustained recovery is very hard to achieve with absent post discharge support.

I never rotated through a state mental hospital. I saw some people who stepped down from them. I imagine the benefit there is primarily in learning the legal system that landed them there and things like restoration to competency/capacity to stand trial. I will say that the only staff deaths I've read about have been at state mental hospitals, although obviously assaults are everywhere. It's a tricky place because patients are accused, but not convicted of a crime, so their rights are very nebulous and it seems to lead to likely inappropriate privileges for extrarordinarily dangerous people in some cases.

Now private psych hospitals...not my favorite. I never rotated as a resident, but I did moonlight. Of all the sites, these are the only ones with some really nasty conflicts of interest. They are the only ones paid by the patient per day and you can see how this would not be ideal when people's human rights are on the line. Obviously the formulary is broad and most inpatient psychiatrists do work in this setting, so it's good to see it. Care coordination is challenging since so many different insurances are involved. It's not a single system like the others. Patients will likely vary the most here. You'll see a couple Medicaid patients most likely, but not most since they are very poor profit prospects and can be avoided with cherry picking (even if technically illegal). Depending on the arrangement with your program, attendings might view time with you as a money losing part of the equation in this setting. Unlike the VA, they aren't on a tour of duty system where they're stuck at the hospital regardless for a set number of hours and thus might as well get some teaching in. There's also IMMENSE pressure to both admit and discharge quickly since that's where the money is. You have to non-stop justify your work to insurance companies.

Anyways, this is a great question, eager to hear other ideas and I'm also interested to know how the OP's program manages to let residents pick inpatient sites.

 

[FlowRate]

Are you trying to choose preferences for rotation locations or something?

The advantage, IMO, is getting broad exposure, if possible. Otherwise, if I had to choose just one optimal setting, it would be a unit in a large, academic general medical hospital. Best to learn to do things the right way and to take care of patients with a lot of psychiatric and medical complexity.

There's a wide range with community, private, and VA, so it highly depends on the specific programs.

 

[ObsequiousAplomb]

Oh such a great question! So there's going to be a great deal of variety. It's interesting that you get a choice in where you rotate as a resident. Ideally, you should see all of these sites. I'm, of course, highly biased towards VA. Starting with the best...the VA has a lot of resources. You're going to get comfortable with a relatively homogenous patient population and how to treat them. Illnesses are generally less severe than other hospitals and you aren't going to be pressured to discharge people early or ever consider financial aspects in general. Attendings are rarely overworked and generally have a lot of time for teaching. The big con is malingering. It's severe and will be an issue most days because the potential benefits of disability are significant (more money than you will make as a resident counting taxes). That said, while it can be draining, malingering and factitious disorder management is a critical skill to develop as a resident and the VA can be a great way to master it. It can be much more subtle than at other sites. Also, you do get to (occasionally) treat an honest to goodness war hero, which is really cool.

I spent the bulk of my inpatient time in residency in a county Medicaid psych unit which I'm guessing is what you meant by community. It's rough. The patients are extremely sick and the resources are extremely limited. You'll discharge a chunk of people to the street with just $200 in general assistance. You'll really get down deep into why the homeless problem exists in the US at a granular level. On site violence is a pretty common concern, although gun ownership is obviously less than at the VA and thus post discharge concerns of violence are sometimes a bit less. County psych also has a very limited formulary in my experience. You'll get familiar with Target's $10 generic list. It can be soul crushing, but it's where to see the sickest of the sick. Diagnoses are not challenging, but sustained recovery is very hard to achieve with absent post discharge support.

I never rotated through a state mental hospital. I saw some people who stepped down from them. I imagine the benefit there is primarily in learning the legal system that landed them there and things like restoration to competency/capacity to stand trial. I will say that the only staff deaths I've read about have been at state mental hospitals, although obviously assaults are everywhere. It's a tricky place because patients are accused, but not convicted of a crime, so their rights are very nebulous and it seems to lead to likely inappropriate privileges for extrarordinarily dangerous people in some cases.

Now private psych hospitals...not my favorite. I never rotated as a resident, but I did moonlight. Of all the sites, these are the only ones with some really nasty conflicts of interest. They are the only ones paid by the patient per day and you can see how this would not be ideal when people's human rights are on the line. Obviously the formulary is broad and most inpatient psychiatrists do work in this setting, so it's good to see it. Care coordination is challenging since so many different insurances are involved. It's not a single system like the others. Patients will likely vary the most here. You'll see a couple Medicaid patients most likely, but not most since they are very poor profit prospects and can be avoided with cherry picking (even if technically illegal). Depending on the arrangement with your program, attendings might view time with you as a money losing part of the equation in this setting. Unlike the VA, they aren't on a tour of duty system where they're stuck at the hospital regardless for a set number of hours and thus might as well get some teaching in. There's also IMMENSE pressure to both admit and discharge quickly since that's where the money is. You have to non-stop justify your work to insurance companies.

Anyways, this is a great question, eager to hear other ideas and I'm also interested to know how the OP's program manages to let residents pick inpatient sites.

This is a great summary. I always love hearing you talk about the VA you work at, it sounds nicer than the one I rotated through in residency and it's good to know there are some great VAs out there.

I'll add some where I've had more experience.

State hospitals do have some of the forensic experience you mentioned, but state hospitals are just as disparate as VAs. Some state hospitals are 100% forensic, others 66%, 50%, 30% etc. The populations on the civil and forensic sides tend to be quite similar - usually it's the same patient they just got committed this time instead of prosecuted. They're the sickest of the sick. Some major benefits to learning in a state hospital system include exposure to long-term psychotherapy for the inpatients. Residents who train at state hospitals then have some exposure to a population that they otherwise would not have been able to treat with psychotherapy, as these patients don't come to outpatient appointments where most residents learn their long-term psychotherapy skills.

Private for-profit hospitals tend, in my experience, to have a formulary just as limited as the state hospitals. So many only have Abilify and don't have Rexulti or Vraylar on formulary, for example, with the pharmacists saying silly things like "they're basically the same drug" or "as long as there's one of each of the three generations on formulary, there's no reason to have any more options available." Having served on the pharmacy committees for both a for-profit and a state hospital, I wouldn't say that their formularies are appreciably different nor are the arguments made by non-psychiatrists any more informed on the actual data.

I personally was never assaulted at a state hospital. It's happened at the private for-profit ones twice, both times were because the patient was floridly psychotic and mistook me for a police officer. In terms of staff, I've only ever known of state hospital employees to be killed or have femur or skull fractures. That might be a bias in what I hear, though.

 

[slowthai]

I don't get to pick, I'm just curious about what my particular setting would make me strong/weak in. Moreover, I'm curious to know what attending life looks like in these various settings, as I've got an interest in doing inpatient after residency.

 

[ObsequiousAplomb]

I don't get to pick, I'm just curious about what my particular setting would make me strong/weak in. Moreover, I'm curious to know what attending life looks like in these various settings, as I've got an interest in doing inpatient after residency.

Workload stereotypes:

State hospital: 20-30 patients, but writing notes from once a week to once a month, maybe less, depending on the state and how long the patient has been there. Lots of meetings. Lots of paperwork. Generally not allowed to dip out in the afternoons. Pay is between VA and private.

VA: 8-10 patients, with enough extra paperwork that you're busy all 8 or 10 hours. Definitely have to stay at work the full tour of duty. Lowest pay, but it's great money still.

Private-for-profit: 40+ patients with daily notes but you're providing such minimal care that you have plenty of time to go to your second job in the afternoon. Unless you have court, in which case your day is ruined. Highest pay, highest burnout.

Correctional: such a mixed bag since no two states have similar systems. You could be a locums doc in CA making $350+ per hour or you could be employed by the system for terrible salaries, like seriously below $200k still in many places. There's a poster on here who has an amazing corrections job though. He makes extreme bank and loves it. He might be the only one though.

 

[Sushirolls]

When I was a med student and ranking Residency Programs, I looked for programs that had minimal, or no exposure to the VA.

 

[comp1]

When I was a med student and ranking Residency Programs, I looked for programs that had minimal, or no exposure to the VA.

That is very unfortunate and dramatically limited your options. The VA, in addition to being the single largest provider of healthcare in the world, is also the largest provider of resident education. The large majority of residents in all specialties (outside peds, but including OB/GYN) did some training at the VA. You cut out a massive swath of programs by limiting time at the VA, in addition to missing out on great education in general.

 

[Sushirolls]

I just ranked those programs lower. We each have (had) things to with which to evaluate a program and shape the rank list. My experience with the VA as student was anything but impressive, and its a narrowed population. When training, we need broader population. Many Psych programs don't / can't exist without VA training/money. CCF and Mayo are 2 programs that have limited to no VA exposure, and have a program health that they don't need the VA to stay afloat.

 

[Celexa]

I think some VA is usually good. If nothing else, working long term for the VA comes with very clear pluses and minuses that people tend to feel strongly about and sorting that out in training is helpful. I know many people who happily took VA positions and others (myself included) happy to never work there again.

In general variety in training is good for both clinical experience and choosing what you want to do after. However one thing to think about is that with limited outpatient exposure most junior residents tend to greatly overestimate the importance of inpatient and the liklihood they'll want to work inpatient long term. Outpatient variety is just as or more important. After all, the majority of psychiatric care takes place outpatient.

 

[psych_0]

There's also IMMENSE pressure to both admit and discharge quickly since that's where the money is.

You have to non-stop justify your work to insurance companies.

Please explain how both of these statements can be true at the same time? I have friends who work at private psych hospitals. There is basically 0 thinking involved. After admission, UR figures out how many days the patient is approved for and that is how long the patient will stay in the hospital: no more, no less. Your documentation says that person is suicidal or psychotic every day until their "days are up" then you document that they are stable for discharge on day of discharge. This works out well for borderlines and malingerers who want to stay as long as possible. This is awful for those who made some b.s. suicidal statement in the heat of the moment while drunk and were never truly suicidal. They get held involuntarily until their "days are up" and go home with horror stories and a hatred for psychiatry.

My friends at these places never have utilization reviews (peer to peers) because of the above documentation. If they want to discharge someone before their "days are up," they need a second opinion from another colleague psychiatrist saying they agree the patient can be discharged "early." So, in reality, it never happens. It's not rewarding work but it pays their bills and helps them avoid the endless pit of burnout that is outpatient clinic.

 

[comp1]

So yes, it's definitely better than outpatient, any inpatient setting is. But what you described in terms of UR is...really bad care. Like horrifically bad. I'm not saying you're wrong, it's why I don't do private inpatient, but it's really, really bad. The way private inpatient SHOULD work is that there is no predefined length of stay, there might be a preapproval based on the admission information, but it's just an upper limit before you again have to re-justify the hospitalization. It certainly says or means nothing at all about whether the patient is ready to discharge before that upper limit. This sort of thing is not common in the public sector. There's often no justification of hospitalization. If the doctor says they need to be there, that's just the end, outside of involuntary hold hearings. In terms of why there is pressure to admit and discharge, look at average payments or RVUs. Admit notes are come back between $300-$400, progress notes $100 and discharge day like $200? It's hard to find these numbers, but the multiples are at least going to be around there. However, if I'm a public sector salaried employee...it's all the same to me.

 

[bashir]

Please explain how both of these statements can be true at the same time? I have friends who work at private psych hospitals. There is basically 0 thinking involved. After admission, UR figures out how many days the patient is approved for and that is how long the patient will stay in the hospital: no more, no less. Your documentation says that person is suicidal or psychotic every day until their "days are up" then you document that they are stable for discharge on day of discharge. This works out well for borderlines and malingerers who want to stay as long as possible. This is awful for those who made some b.s. suicidal statement in the heat of the moment while drunk and were never truly suicidal. They get held involuntarily until their "days are up" and go home with horror stories and a hatred for psychiatry.

My friends at these places never have utilization reviews (peer to peers) because of the above documentation. If they want to discharge someone before their "days are up," they need a second opinion from another colleague psychiatrist saying they agree the patient can be discharged "early." So, in reality, it never happens. It's not rewarding work but it pays their bills and helps them avoid the endless pit of burnout that is outpatient clinic.

I just want to state the obvious and echo comp1. This is not simply "not rewarding work." This is normalization of routine civil rights violations under the the guise of psychiatric care. I don't know how someone practicing under this model of "care" can sleep at night, but they definitely don't deserve to. If I knew where this was happening I'd be on phone with a journalist about it. I trained in the same locale I now work so I can't speak to common practice in other areas of the country, but I really hope this is rare. I have not encountered any inpatient docs who practice this way in my city, even the most terrible ones.

 

[psych_0]

.really bad care. Like horrifically bad

Well, duh. I am not saying I approve of how they practice; I am just pointing out the reality of how a lot of places practice. I turned down an offer in my city with this exact practice style. On my unit, I would say my average length of stay is somewhere between 24-48 hours. No one is "pressuring" me to discharge that quickly. I just deal with a lot of malingering, "drunk-icidal" involuntary holds, and drug-induced psychosis that resolves overnight with sobriety. I feel an obligation to free these folks from the hospital and try my best to document why they should not just be re-admitted when they walk from my unit to the hospital's ER requesting admission later in the afternoon.

 

[sloh]

Please explain how both of these statements can be true at the same time? I have friends who work at private psych hospitals. There is basically 0 thinking involved. After admission, UR figures out how many days the patient is approved for and that is how long the patient will stay in the hospital: no more, no less. Your documentation says that person is suicidal or psychotic every day until their "days are up" then you document that they are stable for discharge on day of discharge. This works out well for borderlines and malingerers who want to stay as long as possible. This is awful for those who made some b.s. suicidal statement in the heat of the moment while drunk and were never truly suicidal. They get held involuntarily until their "days are up" and go home with horror stories and a hatred for psychiatry.

My friends at these places never have utilization reviews (peer to peers) because of the above documentation. If they want to discharge someone before their "days are up," they need a second opinion from another colleague psychiatrist saying they agree the patient can be discharged "early." So, in reality, it never happens. It's not rewarding work but it pays their bills and helps them avoid the endless pit of burnout that is outpatient clinic.

Out of curiosity, how much do these types of gigs pay?

 

[ObsequiousAplomb]

Out of curiosity, how much do these types of gigs pay?

in DC the UHS hospital pays less than $220k w2, they operate that way.

 

[psych_0]

Out of curiosity, how much do these types of gigs pay?

I have 2 friends who make >500k/year. One makes >600k but also does ECT.

 

[michaelrack]

Please explain how both of these statements can be true at the same time? I have friends who work at private psych hospitals. There is basically 0 thinking involved. After admission, UR figures out how many days the patient is approved for and that is how long the patient will stay in the hospital: no more, no less. Your documentation says that person is suicidal or psychotic every day until their "days are up" then you document that they are stable for discharge on day of discharge. This works out well for borderlines and malingerers who want to stay as long as possible. This is awful for those who made some b.s. suicidal statement in the heat of the moment while drunk and were never truly suicidal. They get held involuntarily until their "days are up" and go home with horror stories and a hatred for psychiatry.

My friends at these places never have utilization reviews (peer to peers) because of the above documentation. If they want to discharge someone before their "days are up," they need a second opinion from another colleague psychiatrist saying they agree the patient can be discharged "early." So, in reality, it never happens. It's not rewarding work but it pays their bills and helps them avoid the endless pit of burnout that is outpatient clinic.

This is highly state dependent and age dependent (doesn't apply to geriatric, and things are usually different for adults vs children). I have in the past or still am worked at private psychiatric hospitals in Arkansas, TN, and Mississippi; at hospitals that had high medicaid populations. But they weren't exclusively medicaid so a psychiatrist can't operate on auto pilot.

"Your documentation says that person is suicidal or psychotic every day until their "days are up" then you document that they are stable for discharge on day of discharge". I used to do some work at an Arkansas child psych hospital. Many of the Arkansas medicaid plans require that those criteria are met for the entire hospital stay; the insurance reviewer will review for more days if needed. I don't like working in Arkansas; I recently stopped working in Arkansas except for some supervision of a medical nurse practitioner. The criteria to be suicidal or psychotic every day is unrealistic for kids.

TN medicaid (for both adults and children): TN medicaid works pretty well. Every couple of days the patient comes up for reviewer, and I tell the insurance reviewer whether to review or not. When a patient is about ready to go (or if a review is denied); you let the insurance company know that and you are given several guaranteed days (the patient doesn't need to meet criteria during those days) for discharge planning. IF a review is denied, I can do a peer to peer.

MS medicaid: a little different for adults vs children.... let me confine my comments to kids. Most MS medicaid plans cover up to 19 days of hospitalization (and if I need more would typically need to do peer to peer... this is very rare). However, payments to the hospital are front-loaded, and most kids/families don't want them there 19 days anyway. So the typical hospital stay is less than half of the covered 19 days. Although from a doctor's perspective, my billing of MS medicaid is based on CPT code and is not front-loaded.

I do have some privately insured patients as well. I am the one who decides if to review for more days and when to discharge. I of course rely on feedback from the reviewer. I will do a peer to peer review if needed, although this is usually less than once a month. My peer to peers typically go well; unless the patient has to remain in the hospital for pure placement issues.

I am an inpatient psychiatrist who runs my treatment teams and does not operate on autopilot.