Psychologists that work at hospitals

[psych844]

First, happy new year to everyone! Hopefully it is a happy and successful one for everyone here!

I was curious about the day-to-day work experience for those of you who work at a regular hospital, or VA, or a mental health hospital. If you have worked in a different setting, do you prefer the hospital setting? And if so, why? I'm also curious about the consulting portion.

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[WisNeuro]

I've worked in some capacity in AMC's, PP, and VA's. I prefer the VA setting, which is where I currently am. In other settings, the amount of hassle that was spent with insurance reimbursement was crazy. Also, people were obsessed with hitting their monthly numbers. There was a lot of work that went on after hours. In the VA, I work 40 hour weeks, if I'm busier with research, I rarely push it to 45-50, but that is pretty rare. I usually have that time available during the week to get it done. I also get plenty of time outside of my clinical work to do supervision and the aforementioned research.

Granted, my experience with AMC's and PP came before the ACA was implemented, so I don't have personal experience as to how those settings have and will become changed by that.

 

[bostongal109]

I LOVE the work in the ED. It's always something interesting, it's fast paced, and time flies. I don't have to worry about reimbursement from insurance companies, because that's not how I'm paid.

Aside from the environment that, because of my personality type, I thrive in, I also love the variety of clients I see. When I was getting my license I realized I didn't even need to study for the exam because I have seen almost every psychiatric illness. It's amazing. Sad at times, but really fascinating.

The downsides can be the relationship between MDs and non MDs (which is typically great, but sometimes there have been struggles, and the longer I've done this the more and more I stand firm in my decision), and the hours. Unfortunately, hospitals never close so my hours can be tough. Also- even if my "shift" is over at 7pm, if a patient decides to tell me they want to kill themself at 6:45pm, it means I'm stuck there for at least another hour or two. So I've missed my fair share of dinners/events/etc. Also- the amount of malingerers or personality disordered patients or drug seeking patients can be really trying.

I find that work in the ED makes me feel like I'm actually making a difference (most of the time) so I don't mind working late, or missing holidays with the family. I don't have resentment for that (whereas I have in other jobs), so it provides a great sense of purpose.

I think the most important thing I've learned is that to work in the ED you must have a good sense of humor. You will be called terrible names, have things thrown at you, lied to constantly, etc so if you can't laugh it off it'd be difficult to be able to go there everyday.

Hope that helps!

 

[Fan_of_Meehl]

First, happy new year to everyone! Hopefully it is a happy and successful one for everyone here!

I was curious about the day-to-day work experience for those of you who work at a regular hospital, or VA, or a mental health hospital. If you have worked in a different setting, do you prefer the hospital setting? And if so, why? I'm also curious about the consulting portion.

My experience in private psychiatric hospitals (during and shortly after graduate training) was in the mid-late 1990's so it's a bit dated now. One thing I liked about working in a private hospital (as opposed to state/federal institutions such as I have worked in for the past decade or so) was the higher degree of accountability of the support staff (clerical, IT, janitorial, human resources, random mid-level bureaucratic positions, etc.) in a private vs. government-run institution. This may seem like a minor complaint but it really has an impact on your personal productivity as a professional provider when, for example, you have to fill out your own requests for simple office supplies/equipment (and, of course 'walk them through' personally because you know it is going to get 'lost' (read--thrown in the garbage) by some federal union ('Untouchable') employee somewhere along the way. I recently moved my office and it was an odyssey just to finally (after 3-4 weeks) to actually get a key to open my own office. I had to take all the initiative, follow up multiple times with multiple people, had the first key I was given not work on the lock (they had screwed up the key numbers in Engineering) and then re-do the whole process. At a private hospital all I would have had to do is tell clerical staff that I needed a key to my office (if I even had needed to do that) and they would take it from there and I would have a working key to my office by the close of business that day or at latest the next day. And yes, I work at a VA Hospital 🙂.

However, at the VA you can't beat the salary, benefits, and job security as compared to private hospital work (though I can only speak to my own experience there and I'm sure there are some really nice private gigs out there). And working as a VA clinician in mental health doesn't force you into mediocrity (in terms of clinical competence, responsibility, and excellence)--only YOU can choose to do that. It's easy to do, there are multiple vectors of pressure to sacrifice quality of your work for quantity (or just kissing up to the boss/bureaucracy) but--again--no one actually is forcing you to do that...it will always be your choice. Just don't expect *external* or tangible rewards for doing a good job as a VA employee (and make peace with that fact) and you'll be okay. Come to understand that the VA system is actually an inverse meritocracy where the least competent/dedicated/ethical people will generally tend to climb the administrative ladder (it's a systems problem) and find a way to develop a niche delivering good clinical care and customer service and derive satisfaction from that. Things may improve long-term in the system but right now this seems to be the case.

Don't get me started on the overdiagnosis/service-connection for PTSD and mTBI issue 🙂. I plan to be on the right side of history of those issues but right now it's a jaw-dropping phenomenon on the front line and a wooly Mammoth in the room that no one wants to discuss.

 

[WisNeuro]

Don't get me started on the overdiagnosis/service-connection for PTSD and mTBI issue 🙂. I plan to be on the right side of history of those issues but right now it's a jaw-dropping phenomenon on the front line and a wooly Mammoth in the room that no one wants to discuss.

🙂 Yeah, this is one of my bigger peeves as well. I do think it differs depending on VA. I, personally have not had pressure from management to diagnose these things. I've done several TBI C&P's, in addition to countless mTBI evaluations over the past several years. As can be expected, most are concluded to be mild with no expected residuals, and I've openly opined about secondary gain issues in some where the evidence warranted it. So far, I've gotten no pushback. If I ever did, I would honestly tell supervisors that I would either not accept mTBI referrals if I couldn't do my job the right way, or simply leave the job.

 

[Fan_of_Meehl]

🙂 Yeah, this is one of my bigger peeves as well. I do think it differs depending on VA. I, personally have not had pressure from management to diagnose these things. I've done several TBI C&P's, in addition to countless mTBI evaluations over the past several years. As can be expected, most are concluded to be mild with no expected residuals, and I've openly opined about secondary gain issues in some where the evidence warranted it. So far, I've gotten no pushback. If I ever did, I would honestly tell supervisors that I would either not accept mTBI referrals if I couldn't do my job the right way, or simply leave the job.

Then I'd say that you're a good example of a case where the policies/administration of an organization cannot force you to abandon your professional ethics and integrity. We need more of that in VA. I think students or other young professionals considering a career at VA need to hear that. I also think that the most elegant and long-term solution to the 'systems' problem is at the individual clinician level. Recently we have had a couple of new psychologists join our department who are kindred spirits (who are interested in making the correct diagnoses, doing the right things, etc.) and it has had a real impact on my job satisfaction just to be able to confer with them as colleagues once a week or so and compare notes and share ideas. I think that if we each individually focus on being the best clinicians we can be (despite VA policies, procedures, hassles, etc.), then a) we feel better due to intrinsically-driven job satisfaction factors (which we control), and b) we exert a small-systems effect on helping kindle the flames of like-minded psychologists around us.

 

[AcronymAllergy]

Then I'd say that you're a good example of a case where the policies/administration of an organization cannot force you to abandon your professional ethics and integrity. We need more of that in VA. I think students or other young professionals considering a career at VA need to hear that. I also think that the most elegant and long-term solution to the 'systems' problem is at the individual clinician level. Recently we have had a couple of new psychologists join our department who are kindred spirits (who are interested in making the correct diagnoses, doing the right things, etc.) and it has had a real impact on my job satisfaction just to be able to confer with them as colleagues once a week or so and compare notes and share ideas. I think that if we each individually focus on being the best clinicians we can be (despite VA policies, procedures, hassles, etc.), then a) we feel better due to intrinsically-driven job satisfaction factors (which we control), and b) we exert a small-systems effect on helping kindle the flames of like-minded psychologists around us.

Agreed as well. I'm in a similar situation to WisNeuro in that I've been asked to evaluate a few such cases (although not nearly as many as I saw on postdoc), and haven't received any pushback whatsoever regarding my diagnoses (or lack thereof). There are still a few folks with whom I work who hold onto the mentality that any h/o brain injury, even mild, equates to permanent problems, but I'm slowly working on re-orienting them with current thinking/research in that area.

As for my day-to-day experiences at my VA clinic, I very much enjoy the setting. There are certainly frustrations involved when working in any large hospital system, and also when working in a large government agency (some of which Fan_of_Meehl pointed out above), but by and large, I appreciate how the VA has thus far let me do my job without having to be huge into bean counting. They're currently working on shifting around the productivity metrics to both increase accountability and more fairly assess workload credits (e.g., for psychologists vs. physicians and NPs), which I actually support to a degree, but not having to go through the headaches associated with insurance billing is a HUGE plus.

My colleagues and supervisors all seem to value what I do, are supportive and (thus far) easy to get along with, and universally value patient care. I see an average of 4 patients/week for full neuropsych evals, and then a handful more for feedback sessions and what not. If I wanted to take any folks on for therapy, I'm sure they'd allow me to build the slots into my clinic, but I'm currently more interested in focusing that time on my existing assessments and other areas like training/teaching, administration, and research.

 

[psych844]

Thanks for the responses so far, but I also wanted to understand how consulting works. How often are consults done with neurology department, oncology, etc.

Also I've heard that psychiatrists in hospital settings simply stick to meds management? Psychologists do all the assessment, diagnosis and treatment?

 

[Therapist4Chnge]

Thanks for the responses so far, but I also wanted to understand how consulting works. How often are consults done with neurology department, oncology, etc.

It depends on the hospital and how departments organize their coverage. For out-pt work, psychologists can receive referrals from many different depts. In my out-pt practice I receive referrals from depts within my hospital system (e.g. Neurosurgery, Neurology, PM&R, etc), and from outside hospitals/practices. My in-pt referrals are based on agreements I have within my dept. Some hospitals run a consult service where they cover multiple depts/areas.; it typically depends on who is paying for your time.

Also I've heard that psychiatrists in hospital settings simply stick to meds management? Psychologists do all the assessment, diagnosis and treatment?

It depends. I've mostly seen psychiatry consulted for meds management and/or consideration for an in-pt stay (for active suicidality).

 

[AcronymAllergy]

As T4C mentioned, the frequency of consults will depend on the setup of the particular hospital/clinic, as well as the area in which you work. In neuropsych where I am, our patients are all referrals, with the primary sources being neurology, primary care, and elsewhere in mental health.

As for psychiatry, the roles T4C mentioned are the primary ones I've seen as well. I've not known psychiatrists who conduct psychotherapy in the traditional sense (i.e., beyond "supportive therapy"), but there might be a sampling bias--hospitalist jobs may just pull for those psychiatrists who aren't as interested in providing psychotherapy.

 

[smalltownpsych]

I work for a private hospital, but my main job is in the outpatient clinic. I am on-call one week out of each month and then I cover the ER, our Crisis Stabilization Unit, and any consults from physicians on the med-surg or ICU. I enjoy working with the physicians and some of what I provide is education and support when physicians are dealing with the interaction between the physical and the psychological. The hospital where I work very much values what psychologists bring to the table and we are treated on an equal footing to the physicians. In fact, a psychologist is part of the overall leadership team. Also, the administration does a good job running the business side and letting us handle the healthcare so I don't have to worry too much about billing issues, I just have to maximize my productivity for my own benefit since my compensation is tied to it.

 

[Fan_of_Meehl]

🙂 Yeah, this is one of my bigger peeves as well. I do think it differs depending on VA. I, personally have not had pressure from management to diagnose these things. I've done several TBI C&P's, in addition to countless mTBI evaluations over the past several years. As can be expected, most are concluded to be mild with no expected residuals, and I've openly opined about secondary gain issues in some where the evidence warranted it. So far, I've gotten no pushback. If I ever did, I would honestly tell supervisors that I would either not accept mTBI referrals if I couldn't do my job the right way, or simply leave the job.

I think it's a fascinating phenomenon--in it's own right and (if there was ever a way to 'get away with it,' studying the subtle and insidious pressures within a system to give or not give certain diagnoses would be fascinating at the VA. I think ya'll have hit the nail on the head in that it's not so much explicit or 'hit you over the head with punishment or negative consequences' contingencies at work (in influencing some biased diagnostic practices) but far more subtle factors including:

a) the 'it just ain't worth it' factor - I have had a lot of people hint (mostly indirectly) at this one. For example, why would I (as a mental health C&P examiner) not just give every applicant for PTSD who can fill out a PTSD Checklist (PTSD self-report) and say that they have nightmares, irritability, sit with their back's to the wall, etc. a presumptive PTSD diagnosis? It's quick, easy, and, hey, if they have 5 or 6 other 'diagnoses' on record in the chart already, your 'No Diagnosis' or 'Adjustment Disorder' diagnosis ain't gonna change their service-connection. Besides, you're potentially (in the long run) facing hassles (from them complaining to the administration, etc.) and/or verbal/physical assault (because you are potentially threatening the income stream of a personality-disordered, undercontrolled, homeless, desperate person with likely real mental health issues (if not PTSD) and they could hurt or kill you. Why in the world would you want to risk all of that? I mean, by just giving the diagnosis, you are really making your job much more difficult/complicated, which gets me to my second factor...

b) the 'you're shooting yourself in the foot' factor - especially with respect to 'productivity,' wRVU's, and performance reviews. I frequently 'get behind' and have a backlog of reports because I'm actually taking the time to do decent differential diagnosis / case formulation to try to figure out what's really going on with each case I see. This makes me look like a 'problem employee' relatively speaking when compared to others who just do a likety-split interview, cursory chart review, and efficiently just build a case for the diagnosis being claimed and are done with plenty of time to spare.

c) the 'conformity factor' - nobody else is engaging in active hypothesis-testing regarding response bias or over-reporting of psychopathology (and giving, at least, an MMPI or other measure that might provide pertinent data), so it must not be a good/advisable thing to do

d) the 'what good will it do...if they come up as exaggerating, what then? (a.k.a., 'Nothing good (and everything bad) can come of testing them.) - I have actually had a colleague state this explicitly.

Problem is, no one is looking at it from a 'systems' perspective (especially over time). Common sense tells ya that the more malingerer's 'push the boundaries,' the more those boundaries will be pushed in the long term (cases in point are situations with folks claiming PTSD who were stationed in Alaska during the Vietnam War and are claiming the criterion A stressor was being told by a drill sargeant that they were gonna get sent to Vietnam (never were sent, actually) and get into combat and be killed. Forty years ago. Ruined the man's life (caused him to become an alcoholic, lose jobs, etc.). If there is no 'pushback' against this kind of thing, it will only continue to get more absurd (maybe, I was thinking the other day how awful it would have been if I were born earlier and were drafted to go to Vietnam and become a prisoner of war...now I have PTSD). Don't laugh--it's coming to a VA near you.

And, most importantly, this is how systems rot and collapse from the inside-out. Each individual just 'looks the other way' (diffusion of responsibility) and the terms/diagnoses drift into less and less meaningfulness or construct-validity. People who are okay with the 'double-think' are rewarded and promoted. People principled enough to be troubled by the system and who stick their heads up to do the right thing are outliers and get attacked (verbally, politically, and perhaps even physically). If, collectively, all of us meerkats would stand on our hind legs and just state/address the obvious, things would be okay and no individual meerkat would be at risk. But that's also a societal problem and I am way off point 🙂

 

[WisNeuro]

I do think there is some institutional pressure, but it is far from consistent from hospital to hospital. At my last VA during postdoc, we conducted, and published on, a lot of PVT/SVT research. If anything, we were encouraged and given plenty of resources to do just that. And, so far, as a new faculty, I've had everything I need to continue some of these lines of research.

Granted, I only rarely do C&P's. But, as said, so far, I've had no pushback from anyone. But, I've seen the other side too. At a different hospital we had a C&P examiner we nicknamed the Rubber Stamp. But, we did some education with him and he has since actually started referring mTBI evals to get a npsych evaluation as part of the process. It's possible to get the change, but definitely not easy. Part of it is training on the front end. I definitely see a difference between providers who have a research background and those who don't. Second, like you said, it takes providers who sometimes go the extra mile, although hopefully still within the bounds of expected workweek and productivity.