reasonable outpatient case load?

[dassie]

What's a reasonable outpatient case load? How do you know when you're "full enough" vs could take on more patients? Do you gauge it by when is the next available return date vs next available intake slot or smoething else?

For context, in our regular outpatient clinics we get scheduled intakes through our PGY2 and 3 years (we just hold onto our patient panel in our senior year) based on how full our schedules are. I don't know the exact algorithm but it's basically just based on how many "free" slots do you have in a 3 month period. This is my first time managing my own intake/transfer schedule so I'm kind of lost as to when I should start saying no or deferring. I'm going to ask my attending but I am also curious how other folks figure this out.

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[whopper]

Depends on a lot of factors. I can tell you this and this is likely person specific, after I reach an amount of patients I start getting drowned in them. E.g. if you have too many tough patients you can get overwhelmed. You also need enough time to respond to calls. Many patients will over-communicate with you but you tell them (train them) on what is appropriate communication and they will call less. If you work 80 hrs a week, however, just doing outpatient the calls will increase proportionately.

Someone else wrote their algorithm for next visit. I forgot where it was but I agree with that very much so and this is something not usually in the training material in residencies.

 

[TexasPhysician]

The goal is to never be completely full. As you stabilize patients, return them to their PCP.

 

[dassie]

Depends on a lot of factors. I can tell you this and this is likely person specific, after I reach an amount of patients I start getting drowned in them. E.g. if you have too many tough patients you can get overwhelmed. You also need enough time to respond to calls. Many patients will over-communicate with you but you tell them (train them) on what is appropriate communication and they will call less. If you work 80 hrs a week, however, just doing outpatient the calls will increase proportionately.

Someone else wrote their algorithm for next visit. I forgot where it was but I agree with that very much so and this is something not usually in the training material in residencies.

I don't feel like I'm drowning in between-visit administrative stuff this year (I definitely was last year) but the problem I'm running to now is more like having enough slots for visits - Aside from my 2 therapy patients in this elective clinic I can't see anyone back sooner than 4-6 weeks, which is *usually* fine but it would be nice to have a little more flexibility for some of the patients I'd like to see back sooner? I don't know if that's unrealistic in the real world setting.

The goal is to never be completely full. As you stabilize patients, return them to their PCP.

Generally agree with this, except for this particular elective I'm doing. lol

 

[hamstergang]

I manage my caseload in terms of time to next follow up. When it gets beyond a month I cut down on number of intakes. The hospital I work for had no problem letting me do this.

 

[romanticscience]

In my practice, patients move from weekly to bimonthly, depending on stability and their commitment. So, openings are in flux. I try to fill out my following week with new intakes but do not schedule much beyond that. I have about 100 +/- 10 active patients. Unlike other providers, I do not allow patients to move to q3-, q6-, or q-12 months. If they don't want to come in bimonthly, I refer them to PCP. This keeps my total patient panel stable.

 

[hamstergang]

In my practice, patients move from weekly to bimonthly, depending on stability and their commitment. So, openings are in flux. I try to fill out my following week with new intakes but do not schedule much beyond that. I have about 100 +/- 10 active patients. Unlike other providers, I do not allow patients to move to q3-, q6-, or q-12 months. If they don't want to come in bimonthly, I refer them to PCP. This keeps my total patient panel stable.

Bimonthly can mean twice per month or every 2 months. Which do you mean? Also, are you doing psychotherapy with everyone?

 

[whopper]

Not every patient will need psychotherapy.

Some of course will. Some will need it more than it's worth it for you as a psychiatrist to do because of the insurance compensation, and if this is the case work with a therapist for that patient.

 

[whopper]

Other factors:
How dependable is the patient with showing up to meetings? If they often times don't show up you either got to terminate them, bill them for a no-show, or strategically place more meetings around the schedule for frequent no-showers.

How burdensome are your patients? Do they emotionally drain you? If so add a therapist to reduce that mental weight.
Do they call you too much? You got to see these people more frequently assuming you're not enabling some type of enmeshment/dependency.

Does the patient just need a refill? How severe are they? (The GAF IMHO shouldn't have been thrown out by the DSM V).

Have a preset playing field of what you will tolerate in your office. Some patients are very obnoxious, rude, and possibly even downright disruptive to you, staff, or the other patients.

 

[DD214_DOC]

Other factors:
How dependable is the patient with showing up to meetings? If they often times don't show up you either got to terminate them, bill them for a no-show, or strategically place more meetings around the schedule for frequent no-showers.

How burdensome are your patients? Do they emotionally drain you? If so add a therapist to reduce that mental weight.
Do they call you too much? You got to see these people more frequently assuming you're not enabling some type of enmeshment/dependency.

Does the patient just need a refill? How severe are they? (The GAF IMHO shouldn't have been thrown out by the DSM V).

Have a preset playing field of what you will tolerate in your office. Some patients are very obnoxious, rude, and possibly even downright disruptive to you, staff, or the other patients.

This. I'm doing exclusively CAPS right now, however I would argue that everything mentioned above is even more important with this population. I don't have some predetermined graduated pattern of follow-up intervals like many seem to. I figure it out during the session based on what is indicated clinically. I've rarely spaced stabl epatients out for more than 3 months, and the reasons for this are because I've found much longer than that and they just return with 6-10 months worth of crap going wrong, which we could have addressed much sooner and prevented. There's almost always *something* that will happen or change with everyone if you carry them on your panel long enough. The second reason is how I painfully learned about the first reason -- even when I say, "f/u 12 weeks", many won't bother to come back for 6-10 months, bringing with them all the crap that happened in the interim.

Ultimately, the f/u interval should have a good rational and clinically-based reason, and not just be some number you pull from the Magic Follow-up Hat.

 

[whopper]

In general most of my patients go through these stages.

1) We figure out the diagnosis. While this is usually done first meeting could take a few meetings especially in odd circumstances.
2) We figure out what meds work best.
3) We figure out the best dosages of the meds that do work.
Once stage 3 is reached I see most patients every 3-6 months. If they still got problems that need addressing it's usually now outside the scope of meds and I refer them to psychotherapy or start working on them with lifestyle changes such as diet, exercise, etc.

But I got oddities as will anyone. E.g. I got people who literally at stage 3 nothing else worked including TMS, ECT, and off-label therapies where we were willing to go there cause the conventional doesn't work. I've tried Buprenorphine for depression, referred pts for Ketamine treatment, the old California-Rocket Fuel (Venlafaxine and Effexor) or pharmacogenetic evaluations.

When you open up a practice most of your patients will be very sick. Once you've been doing it for at least a year you have about a 50-50 mix of sick vs stable cause despite that you stabilized patients they now are once every 3-6 monthers while so you open spots up for new and sicker patients. At about 2 years you got about a 90-10 ratio of stabilized to sick patients where the day goes relatively easy with most of them just needing refills.

During the first year you will likely have more annoying patients that will emotionally drain you with their various cluster B or C problems. At least a few may even act out in the office. Have a prepped plan on what to do such as call the local police. You work on training them to stop calling you over minor issues. Ultimately you will prune a lot of them. E.g. this one patient after I addressed to her over 5x that I should not decide whether or not she should be in her marriage terminated her. Of course I told her she had to figure this one out on her own and that while I could offer some guidance she had to decide herself.

I often times use my wife as a second opinion. She is heavily trained in DBT and has a good balance of holding people responsible while at the same time using empathy. E.g. she'll ask, "did you already tell her you can't make the decision and in doing so you're actually encouraging her not to grow on her own?" Me-Yes. Did you lay it out that if she repeatedly brings this up you're going to either have to terminate her or work on extinguishing this? Me-yes. I also use my colleagues as a second opinion. You have every right to terminate a patient but do so ethically making sure you followed good guidelines.

You will be going through much more stress during the first year or two during this transition. Building up practices that get you to a point of working less, enjoying life more, and actually liking work (cause you get to see stabilized patients that are ongoing reminders that you're making a difference) is a good sweet spot.

Patients that show antisocial traits causing harm to themselves, others, or disruptive to my practice-I have very little tolerance for this. You should too. There is no medical treatment for this personality and tolerating bad behavior could enable it. Patients that mess up but are making sincere efforts, I usually give 2nd and 3rd chances. Patients outright lying, cheating etc, I terminate them pretty quickly.

 

[futuredo32]

This. I'm doing exclusively CAPS right now, however I would argue that everything mentioned above is even more important with this population. I don't have some predetermined graduated pattern of follow-up intervals like many seem to. I figure it out during the session based on what is indicated clinically. I've rarely spaced stabl epatients out for more than 3 months, and the reasons for this are because I've found much longer than that and they just return with 6-10 months worth of crap going wrong, which we could have addressed much sooner and prevented. There's almost always *something* that will happen or change with everyone if you carry them on your panel long enough. The second reason is how I painfully learned about the first reason -- even when I say, "f/u 12 weeks", many won't bother to come back for 6-10 months, bringing with them all the crap that happened in the interim.

Ultimately, the f/u interval should have a good rational and clinically-based reason, and not just be some number you pull from the Magic Follow-up Hat.

You give them 10 months worth of meds???? Or do they run out?

 

[romanticscience]

Bimonthly can mean twice per month or every 2 months. Which do you mean? Also, are you doing psychotherapy with everyone?

Bimonthly = every 2 months. There is some element of psychotherapy to each visit; weekly and q2week visits are usually 60-minutes and have a traditional "therapy" focus (interpersonal, cognitive, psychodynamic). Monthly and q2month visits are 30-minutes and focus on symptoms/medications + supportive interventions. Often people will complete a short-course (~8-12 sessions) before transitioning to less frequent symptom-focused follow-up.

 

[dassie]

In general most of my patients go through these stages.

1) We figure out the diagnosis. While this is usually done first meeting could take a few meetings especially in odd circumstances.
2) We figure out what meds work best.
3) We figure out the best dosages of the meds that do work.
Once stage 3 is reached I see most patients every 3-6 months. If they still got problems that need addressing it's usually now outside the scope of meds and I refer them to psychotherapy or start working on them with lifestyle changes such as diet, exercise, etc.

But I got oddities as will anyone. E.g. I got people who literally at stage 3 nothing else worked including TMS, ECT, and off-label therapies where we were willing to go there cause the conventional doesn't work. I've tried Buprenorphine for depression, referred pts for Ketamine treatment, the old California-Rocket Fuel (Venlafaxine and Effexor) or pharmacogenetic evaluations.

When you open up a practice most of your patients will be very sick. Once you've been doing it for at least a year you have about a 50-50 mix of sick vs stable cause despite that you stabilized patients they now are once every 3-6 monthers while so you open spots up for new and sicker patients. At about 2 years you got about a 90-10 ratio of stabilized to sick patients where the day goes relatively easy with most of them just needing refills.

During the first year you will likely have more annoying patients that will emotionally drain you with their various cluster B or C problems. At least a few may even act out in the office. Have a prepped plan on what to do such as call the local police. You work on training them to stop calling you over minor issues. Ultimately you will prune a lot of them. E.g. this one patient after I addressed to her over 5x that I should not decide whether or not she should be in her marriage terminated her. Of course I told her she had to figure this one out on her own and that while I could offer some guidance she had to decide herself.

I often times use my wife as a second opinion. She is heavily trained in DBT and has a good balance of holding people responsible while at the same time using empathy. E.g. she'll ask, "did you already tell her you can't make the decision and in doing so you're actually encouraging her not to grow on her own?" Me-Yes. Did you lay it out that if she repeatedly brings this up you're going to either have to terminate her or work on extinguishing this? Me-yes. I also use my colleagues as a second opinion. You have every right to terminate a patient but do so ethically making sure you followed good guidelines.

You will be going through much more stress during the first year or two during this transition. Building up practices that get you to a point of working less, enjoying life more, and actually liking work (cause you get to see stabilized patients that are ongoing reminders that you're making a difference) is a good sweet spot.

Patients that show antisocial traits causing harm to themselves, others, or disruptive to my practice-I have very little tolerance for this. You should too. There is no medical treatment for this personality and tolerating bad behavior could enable it. Patients that mess up but are making sincere efforts, I usually give 2nd and 3rd chances. Patients outright lying, cheating etc, I terminate them pretty quickly.

Dang - thank you! I feel like I don’t get a whole lot of advice on this sort of stuff from my attendings directly. This was definitely helpful to read.

 

[whopper]

A huge frustration for me when I was a resident and even a teaching attending is I don't think most teach what's relevant. They don't give you an idiot-proof "this is how it is" explanation.

As I got more experience a lot of the time it's cause they didn't know. Some of it is they didn't care, and some of it was they didn't like teaching.

I'm not claiming to be the best teacher or anything like that but I figure I ought to emphasize what's important (at least what I thought) especially if it's not in the books and lectures.

 

[DD214_DOC]

You give them 10 months worth of meds???? Or do they run out?

They run out. Most will maintain the lie that they've been compliant with meds or, "only missed a couple days", but math doesn't lie. They even maintain the report of compliance when I show them the damn math.

 

[DD214_DOC]

In general most of my patients go through these stages.

1) We figure out the diagnosis. While this is usually done first meeting could take a few meetings especially in odd circumstances.
2) We figure out what meds work best.
3) We figure out the best dosages of the meds that do work.
Once stage 3 is reached I see most patients every 3-6 months. If they still got problems that need addressing it's usually now outside the scope of meds and I refer them to psychotherapy or start working on them with lifestyle changes such as diet, exercise, etc.

But I got oddities as will anyone. E.g. I got people who literally at stage 3 nothing else worked including TMS, ECT, and off-label therapies where we were willing to go there cause the conventional doesn't work. I've tried Buprenorphine for depression, referred pts for Ketamine treatment, the old California-Rocket Fuel (Venlafaxine and Effexor) or pharmacogenetic evaluations.

When you open up a practice most of your patients will be very sick. Once you've been doing it for at least a year you have about a 50-50 mix of sick vs stable cause despite that you stabilized patients they now are once every 3-6 monthers while so you open spots up for new and sicker patients. At about 2 years you got about a 90-10 ratio of stabilized to sick patients where the day goes relatively easy with most of them just needing refills.

During the first year you will likely have more annoying patients that will emotionally drain you with their various cluster B or C problems. At least a few may even act out in the office. Have a prepped plan on what to do such as call the local police. You work on training them to stop calling you over minor issues. Ultimately you will prune a lot of them. E.g. this one patient after I addressed to her over 5x that I should not decide whether or not she should be in her marriage terminated her. Of course I told her she had to figure this one out on her own and that while I could offer some guidance she had to decide herself.

I often times use my wife as a second opinion. She is heavily trained in DBT and has a good balance of holding people responsible while at the same time using empathy. E.g. she'll ask, "did you already tell her you can't make the decision and in doing so you're actually encouraging her not to grow on her own?" Me-Yes. Did you lay it out that if she repeatedly brings this up you're going to either have to terminate her or work on extinguishing this? Me-yes. I also use my colleagues as a second opinion. You have every right to terminate a patient but do so ethically making sure you followed good guidelines.

You will be going through much more stress during the first year or two during this transition. Building up practices that get you to a point of working less, enjoying life more, and actually liking work (cause you get to see stabilized patients that are ongoing reminders that you're making a difference) is a good sweet spot.

Patients that show antisocial traits causing harm to themselves, others, or disruptive to my practice-I have very little tolerance for this. You should too. There is no medical treatment for this personality and tolerating bad behavior could enable it. Patients that mess up but are making sincere efforts, I usually give 2nd and 3rd chances. Patients outright lying, cheating etc, I terminate them pretty quickly.

I wish the non-physicians in my dept who make workflow-related decisions knew this stuff. I'm constantly getting hammered about appointment acquity and why I have unfilled appts. My response was simply, "because I get patients better", didn't seem sufficient.

 

[Trismegistus4]

They run out. Most will maintain the lie that they've been compliant with meds or, "only missed a couple days", but math doesn't lie. They even maintain the report of compliance when I show them the damn math.

I get this all the time too.

Me: Let's see, the last time I saw you was... May! Have you still been taking the citalopram?
Pt: Yes.
Me: Well, the last prescription I gave you was on the date of our last visit in May, and it was for a 30-day supply with 2 refills. You would have run out of that in August. Are you sure you've been taking it every day?
Pt: Yup, I take it absolutely every day!
Me: Hmm, did you get another prescription from someone else? Someone outside our system?
Pt: No.
Me: So, where have you been getting it filled?
Pt: The CVS on Main Street.
Me: Yes, that's where I sent the last prescription to in May... I'm not sure why if you were taking it every day you'd have been able to get it there past August.
Pt: I don't know, but I've been going in every month and picking it up!

 

[st2205]

I get this all the time too.

Me: Let's see, the last time I saw you was... May! Have you still been taking the citalopram?
Pt: Yes.
Me: Well, the last prescription I gave you was on the date of our last visit in May, and it was for a 30-day supply with 2 refills. You would have run out of that in August. Are you sure you've been taking it every day?
Pt: Yup, I take it absolutely every day!
Me: Hmm, did you get another prescription from someone else? Someone outside our system?
Pt: No.
Me: So, where have you been getting it filled?
Pt: The CVS on Main Street.
Me: Yes, that's where I sent the last prescription to in May... I'm not sure why if you were taking it every day you'd have been able to get it there past August.
Pt: I don't know, but I've been going in every month and picking it up!

This is another advantage to high-dose Effexor.

 

[DD214_DOC]

I get this all the time too.

Me: Let's see, the last time I saw you was... May! Have you still been taking the citalopram?
Pt: Yes.
Me: Well, the last prescription I gave you was on the date of our last visit in May, and it was for a 30-day supply with 2 refills. You would have run out of that in August. Are you sure you've been taking it every day?
Pt: Yup, I take it absolutely every day!
Me: Hmm, did you get another prescription from someone else? Someone outside our system?
Pt: No.
Me: So, where have you been getting it filled?
Pt: The CVS on Main Street.
Me: Yes, that's where I sent the last prescription to in May... I'm not sure why if you were taking it every day you'd have been able to get it there past August.
Pt: I don't know, but I've been going in every month and picking it up!

I have got to the point now where I just ask how often they're missing a dose. It has appreciable reduced the frequency of this conversation.

 

[whopper]

The amount you can take is highly related to the amount of frustrating BS you can take.
And this BS amount depends on your tolerance but also how tough the patients are that is highly variable and subject to various manipulations. I work 8:30 to 5 PM. I can afford to work more in terms of what I can handle but don't because I highly prize my time with my family, but where things are with my practice with the amount of frustration I can handle more. I wouldn't have said this 2.5 years ago cause my patients were still being more actively managed.

One more thing I forgot to mention. You're going to have to train patients to be good patients. E.g. patients by default think if they miss a meeting there's no problem. NO. You alert them there's a no show fee. Patients think once they're stabilized they can just stop their meds. NO. Patients think that once you give them a med that they like you can just keep on giving it out indefinitely without them seeing you. NO. If their insurance company doesn't pay for a visit (assuming the doctor's office did everything required to get the payment) that the insurance company was supposed to pay they think they don't have to do anything and it's up to the doctor to get their money. NO.

How people handle this will vary. I tend to let people go out of a no show fee if they've been an otherwise good patient without much BS drama. E.g. if they are full of drama but not of their control or making I don't hold it against them. If they missed the appt due to an emergency that they could prove I let them go. If they're a complaining, finger-pointing judgmental person yeah I'll make them pay the no show fee. If they have a pattern of missing meetings I don't let them go.

Here's a example of a true horror story. 19 year old patient with Opioid Dependence gets stabilized by me on Buprenorphine. She misses her 2nd appt and expects me to refill her without a visit. NO. I tell her on the phone that she has responsibilities as a patient that I clearly pointed out to her on her first visit. (BTW I never expect brand new Buprenorphine patients to actually listen to me other than the words needed to get their hands on Buprenorphine. This is true even of respectful nice people. Withdrawal has a way of making you selectively listen). She gets pissy on the phone, starts saying that she's the customer and I need to satisfy her cause the customer is always right and freaks out. Then she goes on a tirade about how healthcare should be free telling me I'm part of the problem (no this is not mania).

That one idiot just cost me as much frustration and stress as seeing 5 patients without any drama.

Seriously sometimes these cluster B rants are more frustrating than a psychotic guy who tried to punch me on the unit and we injected him with Haldol.

To be nice I remind her she's got to follow the treatment rules, I even let her go the no-show fee. I also try to work her in ASAP my skipping my lunch to squeeze her in. I maintain a pleasant demeanor like Gus Fring from Breaking Bad despite that she's ticking me off.



Next visit. She misses the appt AGAIN.

Well guess what? Now I tell my secretary she can't schedule another appt unless she pays the no show fee. She refuses. ----> Well there you go. She's pruned off of my patient list.

Compare that to another patient, she calls about once a month, she is a very nice lady, respectful but she's got treatment resistant Bipolar Disorder where we've literally tried over 8 meds. Her current regimen has her to the best she's ever been but she still has bouts of irritability that require some fine tuning here and there every few weeks to about every 2-3 months. I never mind her calling cause she knows to only call if it's important. She doesn't call for stupid reasons. When I give her directions she follows them. Despite that I work more time on her case my frustration level treating her is very low and that she gives a damn about her mental illness and she follows the recommendations make it that much more pleasant treating her. She didn't know all the rules of the office but over time has been accommodating and respectful in learning them.

Lots of patients are otherwise fine, respectful, nice people but most of them don't know the ins and outs of being a patient.

So I could work, for example 60 hrs a week and have at tolerate very little BS from a good patient population I treat that has been pruned into a group of stabilized, well-treated, happy with their treatment, and knows how the business operates group, and it's fine.

I could also work 30 hours with a bunch of disrespectful, high-maintenance, belligerent individuals and it's draining on me.

Years ago, while at U of Cincinnati, I took over another doctor's Buprenorphine practice who let patients get away with anything they wanted. Within 3 months I terminated more than half those patients. Things like refusing to pay (and she still saw them), refusing a drug screen, demanding Xanax with the Buprenorphine, and this idiot doctor caved in to all of them.

It was a stressful 3 months.

 

[deleted736562]

The amount you can take is highly related to the amount of frustrating BS you can take.
And this BS amount depends on your tolerance but also how tough the patients are that is highly variable and subject to various manipulations. I work 8:30 to 5 PM. I can afford to work more in terms of what I can handle but don't because I highly prize my time with my family, but where things are with my practice with the amount of frustration I can handle more. I wouldn't have said this 2.5 years ago cause my patients were still being more actively managed.

One more thing I forgot to mention. You're going to have to train patients to be good patients. E.g. patients by default think if they miss a meeting there's no problem. NO. You alert them there's a no show fee. Patients think once they're stabilized they can just stop their meds. NO. Patients think that once you give them a med that they like you can just keep on giving it out indefinitely without them seeing you. NO. If their insurance company doesn't pay for a visit (assuming the doctor's office did everything required to get the payment) that the insurance company was supposed to pay they think they don't have to do anything and it's up to the doctor to get their money. NO.

How people handle this will vary. I tend to let people go out of a no show fee if they've been an otherwise good patient without much BS drama. E.g. if they are full of drama but not of their control or making I don't hold it against them. If they missed the appt due to an emergency that they could prove I let them go. If they're a complaining, finger-pointing judgmental person yeah I'll make them pay the no show fee. If they have a pattern of missing meetings I don't let them go.

Here's a example of a true horror story. 19 year old patient with Opioid Dependence gets stabilized by me on Buprenorphine. She misses her 2nd appt and expects me to refill her without a visit. NO. I tell her on the phone that she has responsibilities as a patient that I clearly pointed out to her on her first visit. (BTW I never expect brand new Buprenorphine patients to actually listen to me other than the words needed to get their hands on Buprenorphine. This is true even of respectful nice people. Withdrawal has a way of making you selectively listen). She gets pissy on the phone, starts saying that she's the customer and I need to satisfy her cause the customer is always right and freaks out. Then she goes on a tirade about how healthcare should be free telling me I'm part of the problem (no this is not mania).

That one idiot just cost me as much frustration and stress as seeing 5 patients without any drama.

Seriously sometimes these cluster B rants are more frustrating than a psychotic guy who tried to punch me on the unit and we injected him with Haldol.

To be nice I remind her she's got to follow the treatment rules, I even let her go the no-show fee. I also try to work her in ASAP my skipping my lunch to squeeze her in. I maintain a pleasant demeanor like Gus Fring from Breaking Bad despite that she's ticking me off.



Next visit. She misses the appt AGAIN.

Well guess what? Now I tell my secretary she can't schedule another appt unless she pays the no show fee. She refuses. ----> Well there you go. She's pruned off of my patient list.

Compare that to another patient, she calls about once a month, she is a very nice lady, respectful but she's got treatment resistant Bipolar Disorder where we've literally tried over 8 meds. Her current regimen has her to the best she's ever been but she still has bouts of irritability that require some fine tuning here and there every few weeks to about every 2-3 months. I never mind her calling cause she knows to only call if it's important. She doesn't call for stupid reasons. When I give her directions she follows them. Despite that I work more time on her case my frustration level treating her is very low and that she gives a damn about her mental illness and she follows the recommendations make it that much more pleasant treating her. She didn't know all the rules of the office but over time has been accommodating and respectful in learning them.

Lots of patients are otherwise fine, respectful, nice people but most of them don't know the ins and outs of being a patient.

So I could work, for example 60 hrs a week and have at tolerate very little BS from a good patient population I treat that has been pruned into a group of stabilized, well-treated, happy with their treatment, and knows how the business operates group, and it's fine.

I could also work 30 hours with a bunch of disrespectful, high-maintenance, belligerent individuals and it's draining on me.

Years ago, while at U of Cincinnati, I took over another doctor's Buprenorphine practice who let patients get away with anything they wanted. Within 3 months I terminated more than half those patients. Things like refusing to pay (and she still saw them), refusing a drug screen, demanding Xanax with the Buprenorphine, and this idiot doctor caved in to all of them.

It was a stressful 3 months.

Yes, 90% of the troublesome patients have serious personality problems.

The way with them is more structure and boundaries, not less. The challenging part is not to internalize what is going on;a lot of the time can fall in the trap of feeling not accommodating, not good enough for them or reacting to their acting out. It's tricky, but really structure and boundaries are your best friends.

 

[DD214_DOC]

Yes, 90% of the troublesome patients have serious personality problems.

The way with them is more structure and boundaries, not less. The challenging part is not to internalize what is going on;a lot of the time can fall in the trap of feeling not accommodating, not good enough for them or reacting to their acting out. It's tricky, but really structure and boundaries are your best friends.

Limits and boundaries are vital for all patients, not just the personality issue ones. This is the best advice I give to the new attendings coming in. Figure out what your limits and boundaries are, and implement them from the very beginning. Your life will become much easier.

 

[whopper]

Agree with you guys fpsychdoc and Hooahdoc.

Someone has a personality disorder, one of the treatments is you hold them accountable for the consequences of their actions.

Some psychiatrists got this erroneous notion that because it's a diagnosable disorder it means medications and you let them go for their bad decisions.

 

[clausewitz2]

Agree with you guys fpsychdoc and Hooahdoc.

Someone has a personality disorder, one of the treatments is you hold them accountable for the consequences of their actions.

Some psychiatrists got this erroneous notion that because it's a diagnosable disorder it means medications and you let them go for their bad decisions.

I think what they were saying was that waiving the fee and squeezing in an extra-special appointment was a mistake.

 

[whopper]

The problem there is plenty of very potential good patients don't know the no-show fee rule until it's told to them. Many new patients have no good experience with being patients. So I tend to let people go for the first no show fee unless they're already showed themselves to be a Richard early on. (Though this person was...and I still let her go).

From my own experience over 50% of patients, once you explain to them the how and why of things like a no show fee they get it. Also the first meeting where they sign the contract that explains the rules? None of them actually read it. They just sign it.

 

[zolof]

The problem there is plenty of very potential good patients don't know the no-show fee rule until it's told to them. Many new patients have no good experience with being patients. So I tend to let people go for the first no show fee unless they're already showed themselves to be a Richard early on. (Though this person was...and I still let her go).

From my own experience over 50% of patients, once you explain to them the how and why of things like a no show fee they get it. Also the first meeting where they sign the contract that explains the rules? None of them actually read it. They just sign it.

Completely agree with you. The issues you echoed above, I encounter as well, but you are so right, I have the rules, office policies Pasted everywhere, in bold, online on the registration form, in the office on paper as well the office manager also reminds them, but still many patients do not get it. One thing I noticed, I tend to focus and get upset the whole week on two or three very difficult encounters and often forget about the majority of patients who make most of the week run smoothly.

 

[Liquid8]

The problem there is plenty of very potential good patients don't know the no-show fee rule until it's told to them. Many new patients have no good experience with being patients. So I tend to let people go for the first no show fee unless they're already showed themselves to be a Richard early on. (Though this person was...and I still let her go).

From my own experience over 50% of patients, once you explain to them the how and why of things like a no show fee they get it. Also the first meeting where they sign the contract that explains the rules? None of them actually read it. They just sign it.

Have been using a tiered system for no-shows - eg. $50, $100, $150 etc. At the core of it, it's about charging how much you think you can get away with without losing the patient. If I like the patient and they're generally well behaved and easy to work with then I might waive any non-attendance charges or keep it at the minimum figure - just as a gentler reminder. If it happens more frequently, the fee goes up and must be settled prior to making another appointment.

If patients miss a new appointment, I start at the highest fee without expecting that I'll actually get anything from them. Had one recently who forgot to show, and when staff called him he agreed to pay the cancellation fee and reschedule. Of course, when it came to the next appointment date he was already trying to get it waived or he'd cancel again. And he enquired about dexamphetamine even though there was nothing about ADHD on the initial referral! Anyone who tries hustling before even meeting isn't a good sign and I was curious - googled the guy's name and found he'd been convicted for over 50 cases of fraud, banned from running a company and other investment related shenanigans etc. Sent that referral back quick smart.

If you want to get rid of a patient, then you can either charge them a higher fee from the outset - or not at all, depending on the circumstances. Had one antisocial PD I discharged after one missed appointment (first followup), and I didn't bill them because I felt that they would have paid it and there would have been pressure and an obligation to allow them to reschedule and keep seeing them.

One thing I noticed, I tend to focus and get upset the whole week on two or three very difficult encounters and often forget about the majority of patients who make most of the week run smoothly.

I think this is completely normal. When my day is done, I don't have to worry about most of my patients, but the difficult ones in crisis or those who play up will always linger in the back of my mind. The other day I got a message from a patient's parent, wanting a call back after 5pm. Had just started them on a new antidepressant a few weeks ago, so expecting things are still not going well. I call back anticipating the worst, just to hear that they're doing some evening shifts and just want to know if Circadin is ok to take if they can't sleep. I ask about the new medication, and am pleasantly surprised to hear that it is going well.

 

[Monocles]

Similar to OP's original question -- one of the hospitals we rotate at recently had some serious staffing shortage (from outpatient attendings leaving to other sites, medical leave, endemic burnout, etc). Our pgy-3 class is now basically picking up the gap from the shortage of attendings in outpatient. Some us of are feeling that this is becoming... less of an education experience. Is there an ACGME cap for outpatient clinic numbers?

 

[MedMan80]

Similar to OP's original question -- one of the hospitals we rotate at recently had some serious staffing shortage (from outpatient attendings leaving to other sites, medical leave, endemic burnout, etc). Our pgy-3 class is now basically picking up the gap from the shortage of attendings in outpatient. Some us of are feeling that this is becoming... less of an education experience. Is there an ACGME cap for outpatient clinic numbers?

Honestly I think the ACGME guidelines are so broad that they can encompass any patient load number..and residents making up for poor staffing is endemic probably in any residency program (this was a regular finding for me in residency and even somewhat in fellowship). What you can do is be more vocal in meetings and stress that this is taking away from the educational experience, this could help them find coverage/new attendings, but obviously this is limited by the financial power of the institution (good luck finding more attendings in a state/city facility with short notice).

I've also felt that I'm getting better at managing my own countertransference's towards patients, of course annoying patients/parents are annoying, especially if there's no pathology apart from personality. But I've found that strict limit setting has been working so far. My VM states that I will callback within 48 business hours, if family's call with a mundane question, I'm in no rush to callback. This sets the precedent that I'm not available for non urgent questions that most of them can be discussed during the next followup as they should (I know a PP model will be different).

 

[futuredo32]

I point out the part of the form and tell them the no show fee which is full fee on their first visit. My biller is really good at getting them to pay. One patient cancels last minute more than he shows. I make a lot of money from him. I inherited him from another psychiatrist, tons of benzos 2 doses of Concerta and Adderall. I am weaning him off slowly. I got THE WORST PATIENTS on the WORST meds from this psychiatrist.

 

[Heart of Lioness]

It depends on many things. How many high acuity Medicaid patients do you take? How long are your appointments? Do you do any brief therapy? When do you consider your wait for a new patient too long? My wait is 2 months and I keep it about there That isn't long for my community.