Reduced Patient Volume This Year?

[zenmedic]

Hey all,

I saw a post today on the facebook private practice group where many of the docs expressed concern over reduced patient volume this year. One cash only CAP doc said for the majority of his career had a wait list of many months, but now is struggling to fill his week. Anyone else notice this in PP and if so any idea why it may be?

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[splik]

this was my 2nd yr of pp and it was a smashing success. There is a high demand for high quality, timely psychiatric expertise.

That said where I am, I’m definitely noticing a glut of NPs in my area and I could imagine that could impact general psych practices. Now that ADHD is the commonest reason to seek private psych care, NPs are the way to go for more seamless access to a dx and industrial quantities of stims.

In areas where people have been affected more by inflation people would likely cut back on things like private pay care. This isn’t a thing in my area however.


Some of those people who complain about getting patients -they don’t market, don’t have a website, don’t network, have not kept up with the times, have terrible online reviews, and are overly selective about patients.

We can choose who we want to see in our practices but if you exclude everyone wanting controlled drugs, SI, psychosis, severe bipolar, substance use disorders, personality disorders, recently hospitalized, medically complex patients, eating disorders, somatoform disorders, dementia, older patients, younger patients etc then don’t be surprised that you can’t fill. You can say no to some of that but not to everything. If you limit your practice like an NP don’t be surprised if you have to compete with them.

 

[ObsequiousAplomb]

Agree with above. I don't advertise, I barely network. I work in a severely saturated market. I still get more than enough referrals.

 

[TexasPhysician]

While I anticipate it happening gradually, the number of psych NP’s is flooding the market. Newer grads will grow practices much more slowly. I’m already seeing this in Texas. If you were planning to grow a practice fast in Texas, I’d think again. In the last 5 years, my 2 practice areas went from about 1 psych NP to over 8. Not sustainable.

 

[finalpsychyear]

almost all the psych nps and other nps are exclusively doing adhd meds and would not survive without it. Been calling this for a long time. Your somewhat more protected in a big box shop model at least in that term but they can boot you out the door at anytime or other nonsense.

Again, I am not touting any doom and gloom ( plenty of 250k jobs w2) but yeah this has come about as expected as we have had a pretty great run 8-9 yrs and have been discussing this topic for the last 5-7 years. Hope i'm wrong but the only hiring at the contract clinic i work at has only been NP turnover finding better pay and no consideration for any MD psych hiring for several years. I have volume loss since peaking around or before covid and have had to work more contract hours to compensate.

Would advise the newer peeps to save/invest more early on. Was hoping i wouldn't see this till earliest 2026 or after but has come earlier then i hoped. I'm probably transitioning out of PP over the next few years if this continues unless they pass laws to get rid of psych collab in all states then I would imagine even as admin role of med dir at the clinic im at, wouldn't be suprprised if i got the boot but hope to be financially ready for it but kinda sucks and its the type of issues a surgeon likely doesn't ever have to worry about or even gas these days which is what i suggest to newbies hopeful for medicine.

 

[calvnandhobbs68]

Some of those people who complain about getting patients -they don’t market, don’t have a website, don’t network, have not kept up with the times, have terrible online reviews, and are overly selective about patients.

Yeah I think this is a significant part of many of these complaints. Many of these people were content with basically doing 0 marketing and still having somewhat of a stream of referrals for cash only patients due to demand being so high. These days, if someone can't find how to get in touch with your office by searching your name online or if you don't have a halfway decent website, you're at a significant disadvantage. There are psychiatrists around me right now who I know exist but I can't even figure out how to find contact info for them online lol.

And yes, as noted above the glut of NPs trying to market to anyone who wants controlled meds is also going to siphon this off.

I think there was also a big boom because everyone felt so crappy during COVID and nobody could get in anywhere that people were used to that level of demand. That's started to taper off.

 

[smalltownpsych]

this was my 2nd yr of pp and it was a smashing success. There is a high demand for high quality, timely psychiatric expertise.

That said where I am, I’m definitely noticing a glut of NPs in my area and I could imagine that could impact general psych practices. Now that ADHD is the commonest reason to seek private psych care, NPs are the way to go for more seamless access to a dx and industrial quantities of stims.

In areas where people have been affected more by inflation people would likely cut back on things like private pay care. This isn’t a thing in my area however.


Some of those people who complain about getting patients -they don’t market, don’t have a website, don’t network, have not kept up with the times, have terrible online reviews, and are overly selective about patients.

We can choose who we want to see in our practices but if you exclude everyone wanting controlled drugs, SI, psychosis, severe bipolar, substance use disorders, personality disorders, recently hospitalized, medically complex patients, eating disorders, somatoform disorders, dementia, older patients, younger patients etc then don’t be surprised that you can’t fill. You can say no to some of that but not to everything. If you limit your practice like an NP don’t be surprised if you have to compete with them.

The few psychiatrists that we have in my area are very limited like this and very few of my patients who need psychiatric treatment fit in this narrow criteria. I work with private pay people and they would prefer to pay more for better service, we just don’t have it. I think one reason for the narrow limits is insurance based practice. Marketing and networking and broader reach need to happen to justify charging more and being able to work with more difficult cases. This can’t really be done in insurance-based because the fee is the generally the same regardless of how much work and liability is really involved.

 

[dl2dp2]

It's true. NPs are flooding most channels. Psychology Today is not very effective anymore. All the online telepsych things are flooding as well. Inquiries are thinner. It's a tougher game now for new grads.

However, my prediction is that this will gradually go away as people get sick of quality, and branding will come back.

 

[calvnandhobbs68]

Would advise the newer peeps to save/invest more early on. Was hoping i wouldn't see this till earliest 2026 or after but has come earlier then i hoped. I'm probably transitioning out of PP over the next few years if this continues unless they pass laws to get rid of psych collab in all states then I would imagine even as admin role of med dir at the clinic im at, wouldn't be suprprised if i got the boot but hope to be financially ready for it but kinda sucks and its the type of issues a surgeon likely doesn't ever have to worry about or even gas these days which is what i suggest to newbies hopeful for medicine.

Around recommending other fields, most fields have some level of cyclicality. Anesthesia was going to be taken over by CRNAs and all the anesthesiologists were going to be out of jobs 10 years ago. Radiology had oversupply when I was in med school, salaries were dropping, nobody was encouraged to go into radiology...now they're as popular as ever. EM was the big "lifestyle" field and then got hit with an oversupply of new grads, consolidation of ERs and NPs all over the place there too.

Surgical subspecialties are probably chronically the safest but then you have to do a surgical residency for 5+ years +/- a fellowship....and you know actually like surgery of some sort.

I think to be clear I'm assuming OP is talking about cash private practice here primarily. Psychiatry is still by far the easiest field to go into private practice due to the low overhead requirements which helps insulate in the long term against a lot of problems other fields have, esp around hospital consolidation. If you take some insurances you'll generally be just fine with filling. People were just used to it being INCREDIBLY easy to do things like cash only telepsych and expecting to be able to fill 20+ hrs/week of this in a few months or do things like charge 400/hr for worried well followups.

 

[finalpsychyear]

Around recommending other fields, most fields have some level of cyclicality. Anesthesia was going to be taken over by CRNAs and all the anesthesiologists were going to be out of jobs 10 years ago. Radiology had oversupply when I was in med school, salaries were dropping, nobody was encouraged to go into radiology...now they're as popular as ever. EM was the big "lifestyle" field and then got hit with an oversupply of new grads, consolidation of ERs and NPs all over the place there too.

Surgical subspecialties are probably chronically the safest but then you have to do a surgical residency for 5+ years +/- a fellowship....and you know actually like surgery of some sort.

I think to be clear I'm assuming OP is talking about cash private practice here primarily. Psychiatry is still by far the easiest field to go into private practice due to the low overhead requirements which helps insulate in the long term against a lot of problems other fields have, esp around hospital consolidation. If you take some insurances you'll generally be just fine with filling. People were just used to it being INCREDIBLY easy to do things like cash only telepsych and expecting to be able to fill 20+ hrs/week of this in a few months or do things like charge 400/hr for worried well followups.

Your right. My concern is the training and online degrees to get into psych NP are too easy and can be done remotely by any XYZ program. Much longer and difficult to go the CRNA route and radiology is too extensive for any real midlevel training and the AI thing is more a tool than replacement.

. Again I dont think it significantly hinders the current attendings in our field. If i was a med student today wanting job security then yes I would def consider surgery and subspecialties, rads, anesthessia and then psych if my interest was pretty similar across the board. Heck even regular medical NPs are jumping into the psych NP track and then the whole tele access you can have some online np psych from any state if they have those regional licenses or what not.

 

[sloh]

It's true. NPs are flooding most channels. Psychology Today is not very effective anymore. All the online telepsych things are flooding as well. Inquiries are thinner. It's a tougher game now for new grads.

However, my prediction is that this will gradually go away as people get sick of quality, and branding will come back.

Their idea of quality is probably not the same as yours though.

 

[zenmedic]

Thanks for the replies everyone! Do you all think going CAP mitigates some of this?

 

[dl2dp2]

Their idea of quality is probably not the same as yours though.

Well yes that's what I meant.

Online mills don't do family meetings, design proper treatment, be thoughtful about meds, etc. People will fail out of online mills and then come back to me. But the normal marketing channels are slowly failing.

I think alternatives will emerge again. It's a bit scary though I think for the junior new grads. There's a lot of reshuffle in this space since COVID.

In particular, I think online mills will compete against managed care/academia/large organizations. They will kill each other. But unclear how fast this will happen yet.

 

[dl2dp2]

Thanks for the replies everyone! Do you all think going CAP mitigates some of this?

Specialist training is always helpful, but is not a panacea. I think you should aim to provide the BEST care for the most complex cases. That would differentiate you as a fellowship-trained MD. NP-driven and online mill based care fails a *lot* is what I realized. But of course if you don't want to deal with complex cases, you'd be SOL.

 

[clausewitz2]

Specialist training is always helpful, but is not a panacea. I think you should aim to provide the BEST care for the most complex cases. That would differentiate you as a fellowship-trained MD. NP-driven and online mill based care fails a *lot* is what I realized. But of course if you don't want to deal with complex cases, you'd be SOL.

Your value proposition for why someone ought to see you over an NP has got to be more than just "well I went to medical school and they didn't." The same applies to "I did a fellowship and they didn't".

The pediatric world shows us that it's perfectly possible to become sub-specialized and have your job and salary prospects get worse.

 

[clausewitz2]

Well yes that's what I meant.

Online mills don't do family meetings, design proper treatment, be thoughtful about meds, etc. People will fail out of online mills and then come back to me. But the normal marketing channels are slowly failing.

I think alternatives will emerge again. It's a bit scary though I think for the junior new grads. There's a lot of reshuffle in this space since COVID.

In particular, I think online mills will compete against managed care/academia/large organizations. They will kill each other. But unclear how fast this will happen yet.

Yeah, back during COVID PT was just a spigot I could turn on as I pleased for new patients, I would easily get 5-6 new intakes a week scheduled. It's slower now; I think last time I opened up for new people I got the same number from PT in closer to a month. You do actually have to find other ways to get your name out there. That said, at least in my neck of the woods, filling is still not a challenge.

 

[brosa]

Honestly I feel bad for MS1s hearing "psych is the new derm" and believing it lol. My area is pretty bad for psych and I have been trying to find something close to 300 for a few months. Friend of mine was offered 240k in a private practice.

I think this is happening because the most savy psychs are hiring NPs instead of MDs, lowering the salaries. Meanwhile friends who have done cards or other lucrative specialties are getting 500k, with zero concern towards NPs.

 

[slowthai]

Honestly I feel bad for MS1s hearing "psych is the new derm" and believing it lol. My area is pretty bad for psych and I have been trying to find something close to 300 for a few months. Friend of mine was offered 240k in a private practice.

I think this is happening because the most savy psychs are hiring NPs instead of MDs, lowering the salaries. Meanwhile friends who have done cards or other lucrative specialties are getting 500k, with zero concern towards NPs.

Psych was never the new derm regardless. Probably the dumbest med school myth I've come across. Just laughable. Even an ortho resident confidently told me this when I told him I was applying psych. It's just ridiculous lol

 

[aquatic ape]

This thread is not consistent with my experience. I’m seeing salaries go up, and my patients and administration seem to be wising up to the fact that NPs are not competent. They haven’t been able to hire MDs, and the answer used to be let’s hire NP, now they are raising the MD salary to try to hire. This is hospital system not private practice.

Cash based private practice is probably slowing because people’s cash reserves are lowering post pandemic, Stimulus, inflation and whatever else. Household savings were at all time high, now are back around average

 

[rjs2131]

Not seeing this in our area (CAP, but part of a larger group PP with multiple adult psychiatrists as well), my next available for a new patient is ~3 months out (though currently only seeing 2 new patients/week or so). I take insurance but our insurance reimbursement is very similar to our cash rates, so it actually works out fairly well for now.

If you want to be successful in PP, especially now, you have to view it as a business and market accordingly. What are you offering that others don't? If I could pay significantly less to receive similar care/results, why would I pay to see a private practice physician?

In addition to specialty training (which I do think over time, families/parents recognize a difference between a CAP and an NP, PA, etc), my patients have email access to me and I'm fairly responsive during business hours (within reason). I spend time with patients/families (90+ min initial, 30 min follow-ups) and work to establish a relationship early on that people value. I keep a running cancellation list so if someone needs to get in sooner, they can email me (this is mutually beneficial and keeps my schedule full).

I don't think the average psychiatrist is doing all of the above, and a lot of this comes down to perceived value vs actual value.

 

[clausewitz2]

In addition to specialty training (which I do think over time, families/parents recognize a difference between a CAP and an NP, PA, etc), my patients have email access to me and I'm fairly responsive during business hours (within reason). I spend time with patients/families (90+ min initial, 30 min follow-ups) and work to establish a relationship early on that people value. I keep a running cancellation list so if someone needs to get in sooner, they can email me (this is mutually beneficial and keeps my schedule full).

In private practice (maybe excepting very large groups), you are a fine dining restaurant or, if you want to be less snooty, at the very least a small bistro or cafe. you are competing with El Bulli or Alinea, not IHOP or Arby's. Yes, those places can churn far more volume than you ever will, but you are fundamentally misunderstanding your business if you are worried about that. You are selling a higher quality of care but you are also selling a better experience of care. Those personal relationships are critical to keep people coming back. They are a big part of what differentiates you from the local CMHC or resident clinic where most patients are fairly indifferent to which "prescriber" they are seeing and don't really expect for anyone to stick around all that long anyway.

I know some of you on this board find any hint of self-promotion as distasteful. Frankly I'd rather sell people on my value as a psychiatrist and get paid for it rather than be an academic and do the same thing for a slightly fancier title and a pat on the head. Unless you work somewhere where people have literally no other choice but see you, this is always going to be something you will benefit from.

This is like half of what old school bedside manner was about.

 

[annoyedpsychiatrist]

Working for a hospital system, the issue doesnt seem to be getting referrals, but rather quality referrals..

If we had exclusionary criteria or screened some of our referrals more, getting rid of the ridiculous drug seeking ones/just overall inappropriate ones, wed quickly fill and build up. Or ones that no show in general and had a low chance of coming. New patients are scheduled 3+ months out. A lot can happen in that time frame, maybe they find someone sooner or things get better.

The quality of referrals for me has dipped this year, and ive discharged a lot of people who have done well and didnt need to see me forever, so at times i feel that that the less appropriate intakes has caused access issues for the appropriate intakes, making slots lower this year.

 

[dl2dp2]

Those personal relationships are critical to keep people coming back. They are a big part of what differentiates you from the local CMHC or resident clinic where most patients are fairly indifferent to which "prescriber" they are seeing and don't really expect for anyone to stick around all that long anyway.

I think it's very important to differentiate yourself in terms of what you are skilled/trained at handling in PP.

Hospital-based practices this aspect doesn't matter that much.

I think if I have garden variety depression or feel fine most of the time and get referred by a PMD for a consult, NP is fine. I get my Lexapro every 3 months and eat my sexual dysfunction and call it a day at $30 copay.

If you want 1. combined strategy with actual real therapy of some sort; 2. a real comprehensive diagnostic interview ruling in or out all DSM diagnoses; 3. you are suicidal, have bonafide diagnoses (bipolar, etc), significant substance use issues, or have high stakes (peripartum, highly complex jobs that requires top shape mental health), or you have a personality disorder that's not responsive to simplistic solutions; 4. if you are a child and need meds. Under these circumstances, I'd absolutely get a well-trained, subspecialtized MD. But you need to explain this well to people.

 

[AcronymAllergy]

From a non-psychiatrist perspective and somewhat related: if you're having any trouble filling your practice but don't want to advertise anywhere and everywhere, consider reaching out to psychologists/neuropsychologists in your area and letting them know what you do/see and that you're accepting new patients. Lord knows, I'm always looking for high-quality treatment referral resources to give to patients.

 

[brosa]

Anyone here following the oldest trick in the book of doing inpatient in the morning as 1099 and then outpatient clinic in the afternoon? Most patients would want to follow up with you after hospitalization.

 

[calvnandhobbs68]

Anyone here following the oldest trick in the book of doing inpatient in the morning as 1099 and then outpatient clinic in the afternoon? Most patients would want to follow up with you after hospitalization.

Unless you're very aware of your payor and patient mix that's not exactly a great setup for a sustainable outpatient clinic. A lot of inpatient admissions especially on more acute units are medicaid coverage or even uninsured. If you were working at a private hospital that only took mostly private insurance or something maybe it'd work out more but you'd still end up with a pretty acute outpatient clinic if that was your main referral source.

People who do/did this generally don't use the inpatient unit as a referral for their outpatient clinic, they're just two totally separate things they've got going on. At least that's the way it was with the attendings I was working with.

 

[FlowRate]

I think it's very important to differentiate yourself in terms of what you are skilled/trained at handling in PP.

Hospital-based practices this aspect doesn't matter that much.

I think if I have garden variety depression or feel fine most of the time and get referred by a PMD for a consult, NP is fine. I get my Lexapro every 3 months and eat my sexual dysfunction and call it a day at $30 copay.

If you want 1. combined strategy with actual real therapy of some sort; 2. a real comprehensive diagnostic interview ruling in or out all DSM diagnoses; 3. you are suicidal, have bonafide diagnoses (bipolar, etc), significant substance use issues, or have high stakes (peripartum, highly complex jobs that requires top shape mental health), or you have a personality disorder that's not responsive to simplistic solutions; 4. if you are a child and need meds. Under these circumstances, I'd absolutely get a well-trained, subspecialtized MD. But you need to explain this well to people.

In our system, there's really not a lot of value add to a MHNP beyond most of the PCP's. Which is different, I surmise, from the typical outpatient world where PCP's may have a narrower typical range of what they're comfortable treating. But I would hope a typical FFS PCP could also start an SSRI instead of referring.

 

[Attending1985]

As someone who has been envisioning private practice this thread is scary and depressing

 

[comp1]

I'm having trouble thinking of a worse referral source than inpatient admissions unless your goal is some sort of personal fulfillment/higher calling as opposed to money. These are some of the sickest, highest need people with the absolute least of resources.

 

[brosa]

No personal fulfillment, just curious as this worked well in my home country. Also talked to a guy doing that and was curious about it. May not be the best population, but still is some source of referral, since it may get worse in the future.

 

[calvinhobbes]

Some states don’t allow NPs to prescribe controlled meds such as stimulants, which is great. Those states are awesome to be a psychiatrist in. In other states, well you know it’s bad when the NP orders a STAT CT head for a mildly elevated prolactin to rule out a brain tumor, when the patient is asymptomatic and then the NP has no idea why they ordered the prolactin to begin with… (true story, sigh).

Point is, NPs are dumb as rocks. They even beg to be called DNPs and call the hospital EMR managers pleading to change their title in the EMR from “Nurse Practitioner” to “Doctor” (Also true story…)

The worst and best thing to happen to medicine was NPs. Worst, well because you know why. Best? Because they are outcompeting each other, saturating the market, driving their own salaries down, realizing their education is ****, and they are all going back to RN nursing gigs anyway because they “can’t handle the stress” of thinking like a doctor. (Just look at their Reddit page lol, they all complain that seeing 15 patients a day “is too hard)”.

We have nothing to worry about, friends. Psych NPs give me and ya’ll more business, as my patients prove to me on a daily basis. I have patients asking me if they truly have bipolar disorder and ADHD and PTSD and why oh why isn’t the Vyvanse their NP started helping with their depression … (🙃)

 

[AcronymAllergy]

As someone who has been envisioning private practice this thread is scary and depressing

I wouldn't be too worried about it, although it can depend on the market/area. There are plenty of places where there's a substantial need for quality mental health (and particularly psychiatric) care. I don't see that need decreasing anytime soon.

Some states don’t allow NPs to prescribe controlled meds such as stimulants, which is great. Those states are awesome to be a psychiatrist in. In other states, well you know it’s bad when the NP orders a STAT CT head for a mildly elevated prolactin to rule out a brain tumor, when the patient is asymptomatic and then the NP has no idea why they ordered the prolactin to begin with… (true story, sigh).

Point is, NPs are dumb as rocks. They even beg to be called DNPs and call the hospital EMR managers pleading to change their title in the EMR from “Nurse Practitioner” to “Doctor” (Also true story…)

The worst and best thing to happen to medicine was NPs. Worst, well because you know why. Best? Because they are outcompeting each other, saturating the market, driving their own salaries down, realizing their education is ****, and they are all going back to RN nursing gigs anyway because they “can’t handle the stress” of thinking like a doctor. (Just look at their Reddit page lol, they all complain that seeing 15 patients a day “is too hard)”.

We have nothing to worry about, friends. Psych NPs give me and ya’ll more business, as my patients prove to me on a daily basis. I have patients asking me if they truly have bipolar disorder and ADHD and PTSD and why oh why isn’t the Vyvanse their NP started helping with their depression … (🙃)

Obviously because they should be using the Vyvanse to offset the drowsiness caused by the Xanax they use to treat their PTSD. They probably need ECT and ketamine for the depression. Throw in some Risperdal because...reasons.

 

[VA Hopeful Dr]

Working for a hospital system, the issue doesnt seem to be getting referrals, but rather quality referrals..

If we had exclusionary criteria or screened some of our referrals more, getting rid of the ridiculous drug seeking ones/just overall inappropriate ones, wed quickly fill and build up. Or ones that no show in general and had a low chance of coming. New patients are scheduled 3+ months out. A lot can happen in that time frame, maybe they find someone sooner or things get better.

The quality of referrals for me has dipped this year, and ive discharged a lot of people who have done well and didnt need to see me forever, so at times i feel that that the less appropriate intakes has caused access issues for the appropriate intakes, making slots lower this year.

FP here, our hospital psychiatry group outright refuses all ADHD and anxiety patients since the majority of the time both groups are just seeking controlled substances. I have to imagine that has helped with their quality of life quite a bit.

 

[calvnandhobbs68]

FP here, our hospital psychiatry group outright refuses all ADHD and anxiety patients since the majority of the time both groups are just seeking controlled substances. I have to imagine that has helped with their quality of life quite a bit.

This is weird and kind of just overall lame. I get maybe adult ADHD evals unless there’s a formal system for this with appropriate expectations for the patients going into it.

But all ADHD patients? And all anxiety disorder patients of any kind? I mean that’s exactly what @splik was talking about. Maybe this works in a hospital system where demand far exceeds supply and people don’t have a ton of incentive to see more patients but this would cut off like half your typical outpatient load lol. And honestly suck for a significant portion of patients psychiatry could honestly help even if it’s a little difficult.

 

[VA Hopeful Dr]

This is weird and kind of just overall lame. I get maybe adult ADHD evals unless there’s a formal system for this with appropriate expectations for the patients going into it.

But all ADHD patients? And all anxiety disorder patients of any kind? I mean that’s exactly what @splik was talking about. Maybe this works in a hospital system where demand far exceeds supply and people don’t have a ton of incentive to see more patients but this would cut off like half your typical outpatient load lol. And honestly suck for a significant portion of patients psychiatry could honestly help even if it’s a little difficult.

Eh, ADHD evals in kids are usually pretty straightforward. If they're pre-puberty I'm comfortable doing them most of the time.

As for anxiety, I think the problem they were having is that the majority of their referrals were people who either came to a primary care doctor already on a benzo that that doctor didn't want to write or the primary care doctor is the one that got them on it in the first place and now doesn't want to write their tid Xanax.

I get maybe one patient a year whose anxiety I can't get a handle on unless the whole issue is that they used to be on a benzodiazepine and I'm not going to write that anymore.

 

[Atreides]

FP here, our hospital psychiatry group outright refuses all ADHD and anxiety patients since the majority of the time both groups are just seeking controlled substances. I have to imagine that has helped with their quality of life quite a bit.

That's bizarre. Not treating anxiety? You realize that benzos are not first (or second or third) line for treating anxiety, right? I get a refusal to prescribe benzos for outpatient anxiety but not to treat anxiety at all? That's ridiculous.

 

[Bartelby]

As for anxiety, I think the problem they were having is that the majority of their referrals were people who either came to a primary care doctor already on a benzo that that doctor didn't want to write or the primary care doctor is the one that got them on it in the first place and now doesn't want to write their tid Xanax.

I think a better approach is to briefly screen patients and know they are on benzos. If so, during screening let them know upfront that the plan will be to taper them and that by starting treatment with the clinic they are agreeing to this. If they aren't happy with that, they can move on to a candyman. If they are okay with it, you can do a lot of good with someone who went into treatment knowing the deal up front. I do this frequently and have had a lot of success stories. The key in my mind is that the patient consented to the taper up front and works with you to make it happen.

 

[Stagg737]

To the original question, I've seen the opposite at our large academic center. It's been getting harder and harder to get patients into a psychiatrist in a timely manner where I'm at. The outpatient clinic's wait time for a psychiatry intake is currently 6-12 months where it was previously 2-3 months a year or two ago. That includes the resident clinic.

 

[DOswag]

I'm in my second year of outpatient practice on the civ side after a few years in military after residency. I have seen no drop off in new patients or decrease in patient volume. I have seen an astronomical increase in the number of patients who come in saying "I saw this tik tok video showing XYZ and that sounds exactly like what I'm experiencing" which 1000% of the time it's either adhd or autism.

 

[VA Hopeful Dr]

I think a better approach is to briefly screen patients and know they are on benzos. If so, during screening let them know upfront that the plan will be to taper them and that by starting treatment with the clinic they are agreeing to this. If they aren't happy with that, they can move on to a candyman. If they are okay with it, you can do a lot of good with someone who went into treatment knowing the deal up front. I do this frequently and have had a lot of success stories. The key in my mind is that the patient consented to the taper up front and works with you to make it happen.

I mean, sure that might be nice. But I'd rather them refuse anxiety and be able to get my actual bipolar and schizophrenic patients in within a reasonable bit of time than take anxiety referrals and it take 6 to 9 months to get people in true need seen.

 

[dl2dp2]

FP here, our hospital psychiatry group outright refuses all ADHD and anxiety patients since the majority of the time both groups are just seeking controlled substances. I have to imagine that has helped with their quality of life quite a bit.

I find this strange as outpatient eval of ADHD is typically a *cash cow*, especially for cash PP.

I'm guessing for groups that take insurance, this might be too time-consuming. But if yo design it well I don't see why it can't be done.

 

[Attending1985]

I think a better approach is to briefly screen patients and know they are on benzos. If so, during screening let them know upfront that the plan will be to taper them and that by starting treatment with the clinic they are agreeing to this. If they aren't happy with that, they can move on to a candyman. If they are okay with it, you can do a lot of good with someone who went into treatment knowing the deal up front. I do this frequently and have had a lot of success stories. The key in my mind is that the patient consented to the taper up front and works with you to make it happen.

Off topic but what do you do when they initially agree to a taper then get down to a lower dose but resist lowering it more. I have a patient on klonopin who agreed to a taper. Started at 12 mg and we are at 3 but says she can’t reduce anymore.

 

[VA Hopeful Dr]

I find this strange as outpatient eval of ADHD is typically a *cash cow*, especially for cash PP.

I'm guessing for groups that take insurance, this might be too time-consuming. But if yo design it well I don't see why it can't be done.

Our bonuses are tied to patient satisfaction. My understanding is that if you do proper ADHD evaluations that many (most?) adults won't actually have that diagnosis. You tell them that, get a bad review, and in the case here lose a good bit of bonus money.

Plenty of cash pay groups do it, most patients don't want to actually have to pay those prices though.

 

[Bartelby]

Off topic but what do you do when they initially agree to a taper then get down to a lower dose but resist lowering it more. I have a patient on klonopin who agreed to a taper. Started at 12 mg and we are at 3 but says she can’t reduce anymore.

I would weigh risks and benefits. Going from 12 mg total daily dose to 3 mg total daily dose is an absolutely massive improvement, and could really be life saving (for her or, for example, for the people she might have crashed into while driving basically intoxicated). I would re-assess:

• How has she done with the taper up to that point?
• Any signs of a substance use disorder, especially comorbid alcohol or other benzodiazepine use?
• How well-managed is her condition at this point?
• Are there any convincing side effects or adverse effects of treatment?

If she is doing very well on 3 mg with no signs of abusing it or other substances, and if she has been on it a long time, I might consider continuing that lower dose. More likely, I would revisit how we can improve management of her anxiety while still going down further on the Klonopin. Is she in psychotherapy? What about other medication for anxiety, could that be optimized?

I would also be willing to do very small reductions over very long periods of time. For example, decreasing by 0.25 mg each month, and extending that out to two months if she does not feel normalized by the end of the first month. That is not likely to be a major burden in terms of worsened symptom profile, but would allow for a very slow march down to zero.

In general though you deserve a pat on the back for what you've already accomplished! Getting an outpatient from 12 mg of Klonopin a day down to 3 is an amazing service to her, to her family and social network, and to the community that is far less at-risk from her almost certainly impaired behaviors (like driving if she is driving).

 

[clausewitz2]

In general though you deserve a pat on the back for what you've already accomplished! Getting an outpatient from 12 mg of Klonopin a day down to 3 is an amazing service to her, to her family and social network, and to the community that is far less at-risk from her almost certainly impaired behaviors (like driving if she is driving).

This is definitely a place for you to take the win. Unless your model of the harm-dose relationship of benzodiazepenes is very non-linear, you have decreased potential adverse effect by burden by somewhere on the order of 75%. Nobody should scoff at this. You have also done an amazing service to her by making her much less likely to break her hip when she gets older by serious falls.

 

[heartsink]

I mean, sure that might be nice. But I'd rather them refuse anxiety and be able to get my actual bipolar and schizophrenic patients in within a reasonable bit of time than take anxiety referrals and it take 6 to 9 months to get people in true need seen.

Maybe I don't really understand what is implied here by 'true need.' Are mostly functional patients with anxiety less deserving of care than patients with bipolar or schizophrenia? I get that the latter are more likely to have a decompensation +/- re-admission if they don't get quick enough follow up, but I feel the implication that patients with anxiety should suck it up for 6-9 months is not really appropriate either.

 

[Stagg737]

Maybe I don't really understand what is implied here by 'true need.' Are mostly functional patients with anxiety less deserving of care than patients with bipolar or schizophrenia? I get that the latter are more likely to have a decompensation +/- re-admission if they don't get quick enough follow up, but I feel the implication that patients with anxiety should suck it up for 6-9 months is not really appropriate either.

I mean, there's a massive difference between "My anxiety is always at a 3/10 and bugs me but I manage it and function pretty well most of the time" vs the patient that became manic and spent $40k in a week or the schizophrenic patient that get found by neighbors/family covered in their own s***. The latter has a "true need" to be seen by psychiatry ASAP. The former can piddle around with PCP until I either have room or PCP determines that the anxiety is beyond what they can manage.

Case in point, I had an outpatient consult for "treatment resistant anxiety" last week. PCP had started duloxetine 30mg around 2 months prior and patient felt slightly better so self-increased to 60mg 3 weeks before getting in with me. By the time I saw her the anxiety had resolved. Complete waste of an hour that could have gone to someone who legitimately needed to be seen by me. I'll take the RVUs though.

 

[calvnandhobbs68]

Maybe I don't really understand what is implied here by 'true need.' Are mostly functional patients with anxiety less deserving of care than patients with bipolar or schizophrenia? I get that the latter are more likely to have a decompensation +/- re-admission if they don't get quick enough follow up, but I feel the implication that patients with anxiety should suck it up for 6-9 months is not really appropriate either.

I mean...yes? It's like asking who's higher priority for ENT to see, the person with laryngeal cancer or the person with a deviated septum.

That doesn't mean I'd put a blanket ban on referrals for deviated septums though.

 

[ObsequiousAplomb]

This is definitely a place for you to take the win. Unless your model of the harm-dose relationship of benzodiazepenes is very non-linear, you have decreased potential adverse effect by burden by somewhere on the order of 75%. Nobody should scoff at this. You have also done an amazing service to her by making her much less likely to break her hip when she gets older by serious falls.

I agree. I'm under the impression the dose-harm relationship is probably exponential, and 75% risk reduction is an understatement.

The first 75% dose reduction is much easier than the last 25%, in my limited experience. I'd be open to letting that last 3 mg stick there unchanged for several months before pushing for more reduction. As others mentioned, there's plenty of work to do before finalizing the wean. I've had patients at least act very upset that they can't come down the last bit. None of them are arguing with me to keep it at 3. They all at least claim to want to come down further than they have been able.

I'd rather avoid the Klonopin patients altogether though. They frequently don't tolerate the switch to Valium, which is what I try to do on most tapers.

 

[Attending1985]

I would weigh risks and benefits. Going from 12 mg total daily dose to 3 mg total daily dose is an absolutely massive improvement, and could really be life saving (for her or, for example, for the people she might have crashed into while driving basically intoxicated). I would re-assess:

• How has she done with the taper up to that point?
• Any signs of a substance use disorder, especially comorbid alcohol or other benzodiazepine use?
• How well-managed is her condition at this point?
• Are there any convincing side effects or adverse effects of treatment?

If she is doing very well on 3 mg with no signs of abusing it or other substances, and if she has been on it a long time, I might consider continuing that lower dose. More likely, I would revisit how we can improve management of her anxiety while still going down further on the Klonopin. Is she in psychotherapy? What about other medication for anxiety, could that be optimized?

I would also be willing to do very small reductions over very long periods of time. For example, decreasing by 0.25 mg each month, and extending that out to two months if she does not feel normalized by the end of the first month. That is not likely to be a major burden in terms of worsened symptom profile, but would allow for a very slow march down to zero.

In general though you deserve a pat on the back for what you've already accomplished! Getting an outpatient from 12 mg of Klonopin a day down to 3 is an amazing service to her, to her family and social network, and to the community that is far less at-risk from her almost certainly impaired behaviors (like driving if she is driving).

Wow thanks for that. She did fine with the taper until she hit some major conflict with family late summer. She now is doing poorly with lots of complaints of doing better on higher dosages and anger about taper. She was on a qid dosing schedule initially but is now bid. Basically was taking it before anytime she left the house and she’s complaining of social anxiety without it. Her diagnosis is borderline personality disorder and she’s dropped out of therapy. Hasn’t returned despite my urging. Declines other med changes.