Should I stay or should I go?

[meow1985]

More of a tl;dr version of my situation. I've gotten better at doing notes fast and doing less outside of appointments, but I don't feel happy in my current job. In fact, I am getting progressively more resentful.

Current job:
300 k per year, salary.
-No call
-35 patient contact hours, 60/30
-complex patient population with lots of substance use, behavioral issues, violence, drug seeking behaviors, inappropriate regimens, court ordered patients, etc. Substance use resources nonexistent in-house. Case management complex to access. No care coordination.
-staff turnover, among MDs and support staff. Not enough support staff. We had no nurse at all for several months. Support staff always overextended, resulting in a culture of MD's having to do things that support staff do in other places.
-small dept, and the MDs who had potential to mentor me left

I talked to current job about considering leaving, and they said they can find me a mentor by recruiting one of the inpatient docs, and there are plans in place to improve support structure in the next year.

Potential new job:
265 k per year first year, then productivity with possibility of making 300+ k, but I'd probably have to work pretty hard
-35 patient contact hours, 60/30 vs 60/20. Most people do a mix.
-patient population more "suburban" and high functioning
-department has a care coordinator, and at least one therapist who does substance use assessments
-2:1 or 3:1 RN to MD ratio, which MDs say works well. MDs report hardly needing to do anything outside of seeing patients.
-Call. q3 mos cover consults at local hospital and phone calls (refills, side effects, things like that). Average 3 patients per day. Also cover phone calls at night 1-2 times per mos (usually nothing past 9 pm but in theory could be woken in middle of night), and cover others' refills/calls during day 2-3 times per mos. The last bit actually makes for a robust safety net if you need to be out.
-large department, and people stay a long time
-the first 2 years are an extended evaluation process, which instantly makes my anxiety shoot up

I already turned down job 2 once before, and I worry I won't get a third chance with them.

I also have to somehow find time and energy to study for boards, so I am thinking of dropping either job to 0.8 at least for a while. But in my present job I don't feel comfortable doing so because things may not be managed appropriately without me. Unless maybe I still work 5 days but have a shorter day and can chill at work and study in the afternoons.

Money matters kind of but not really, won't go into it now. I did make the decision to take job 1 back in the day mostly because of money.

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[AD04]

Go.

You already tried out job #1 and it isn't for you. Extra $35k pre-tax doesn't mean too much, especially if it means burning out.

Job #2 may not pay more now, but by working in a new setting, you'll learn something new which could pay dividends down the road. You'll make over $300k if you code better and document to justify the coding. Low turnover is a good sign so there should be other psychiatrists there you can learn from. And it addresses your biggest complaint: the lack of support staff.

 

[Bartelby]

Job 2 sounds much better to me. Unless there is some compelling reason you really need the 10-15% extra income from job 1 the choice seems pretty clear, especially if you are already burned out in job 1.

 

[dl2dp2]

To be honest, both suck.

 

[meow1985]

To be honest, both suck.

I actually kind of agree with that. I don't feel comfortable with starting my own private practice right now, and almost every job in the area is some variant of Job 2. The higher paying jobs are like 1 - they have something wrong with them from an infrastructure or resources standpoint.

 

[TexasPhysician]

I’m struggling to grasp the true aspects of job 1 that are terrible. Drug seeking behavior and substance abuse patients are everywhere. It is even high in my suburban adolescent patients. That’s psychiatry. I’ve never worked in an outpatient practice with a RN since residency. Thats rare in my area. Are you at a CMHC to expect case management/social workers in house? Beyond referrals, what are you expecting done? The real world is different than residency. Expectations may need to change or maybe academics would be a better fit? Maybe I’m misunderstanding the situation.

 

[meow1985]

I’m struggling to grasp the true aspects of job 1 that are terrible. Drug seeking behavior and substance abuse patients are everywhere. It is even high in my suburban adolescent patients. That’s psychiatry. I’ve never worked in an outpatient practice with a RN since residency. Thats rare in my area. Are you at a CMHC to expect case management/social workers in house? Beyond referrals, what are you expecting done? The real world is different than residency. Expectations may need to change or maybe academics would be a better fit? Maybe I’m misunderstanding the situation.

My expectations may in fact be too high, but MDs at job 2 are saying that they hardly ever have to call a patient, that RNs manage a lot of their practice based on the MD's documentation, and RNs even partially fill out a lot of forms and prepare letters.

Drug seekers - not an issue in and of themselves, but if they are also severely ill, chemically dependent, not medically literate, and not interested in anything that is not a quick fix, and when patients with multiple of the above issues a large part of your practice... That's too much.

Care coordination - I need someone to sit down with my low functioning patients and explain to them the nuts and bolts of how to access recommended care / get in with referrals / get labs/imaging, etc. because if I did that, that would be my entire appointment. The PCPs get care coordinators. Psychiatry does not for some reason.

From a prior post of mine about job 1:

--Triage of intakes is minimal, if any. I get a lot of WTF consults. Basically, anyone can call and get an appointment.
--Things as basic as getting through to the front desk and a reliable mail system are fraught.
--Maybe I am spoiled, but I have also read on this very website that practicing without an RN is not appropriate, especially in a busy, high-acuity population, because RNs can exercise their own clinical judgment while MA's cannot. An MA is ok with a stable population maybe. I've heard the same from colleagues practicing in average, corporate medicine settings, not even academia. Multiple people who left job 1 have felt uncomfortable with the support staff structure. Maybe it's a regional thing.
--Front desk thinks nothing of interrupting my sessions with calls that should go to RN or MA.
--MA/RN/front desk staff saying, passive-addressively and often, that they will *try* to get to things I ask them to do, but they are very short-staffed. So I end up addressing my own envelopes and sending my own faxes if I want it done in a timely manner.
--The current RN/MA situation results in me having to intervene and personally address calls and Mycharts that could have been addressed by supporting staff. At the same time, there have been near misses I am not comfortable with. Examples: things as basic as altered mental status are not further assessed, and messages about mania are not even routed to me high priority. New staff nurse had to ask me what the protocol was for a suicidal patient, which should have been taught in onboarding.
--My coverage partner hardly does anything when I'm gone. Between that and lacking triage, I don't feel safe taking a vacation.

If I have a full schedule, I end up staying 2 hours past end of day to wade through my inbasket and do clerical work that isn't even my clinic notes.

 

[TexasPhysician]

My expectations may in fact be too high, but MDs at job 2 are saying that they hardly ever have to call a patient, that RNs manage a lot of their practice based on the MD's documentation, and RNs even partially fill out a lot of forms and prepare letters.

Drug seekers - not an issue in and of themselves, but if they are also severely ill, chemically dependent, not medically literate, and not interested in anything that is not a quick fix, and when patients with multiple of the above issues a large part of your practice... That's too much.

Care coordination - I need someone to sit down with my low functioning patients and explain to them what referrals are for and how to access recommended care because if I did that, that would be my entire appointment. The PCPs get care coordinators. Psychiatry does not for some reason.

From a prior post of mine about job 1:

--Triage of intakes is minimal, if any. I get a lot of WTF consults. Basically, anyone can call and get an appointment.
--Things as basic as getting through to the front desk and a reliable mail system are fraught.
--Maybe I am spoiled, but I have also read on this very website that practicing without an RN is not appropriate, especially in a busy, high-acuity population, because RNs can exercise their own clinical judgment while MA's cannot. An MA is ok with a stable population maybe. I've heard the same from colleagues practicing in average, corporate medicine settings, not even academia. Multiple people who left job 1 have felt uncomfortable with the support staff structure. Maybe it's a regional thing.
--Front desk thinks nothing of interrupting my sessions with calls that should go to RN or MA.
--MA/RN/front desk staff saying, passive-addressively and often, that they will *try* to get to things I ask them to do, but they are very short-staffed. So I end up addressing my own envelopes and sending my own faxes if I want it done in a timely manner.
--The current RN/MA situation results in me having to intervene and personally address calls and Mycharts that could have been addressed by supporting staff. At the same time, there have been near misses I am not comfortable with. Examples: things as basic as altered mental status are not further assessed, and messages about mania are not even routed to me high priority. New staff nurse had to ask me what the protocol was for a suicidal patient, which should have been taught in onboarding.
--My coverage partner hardly does anything when I'm gone. Between that and lacking triage, I don't feel safe taking a vacation.

If I have a full schedule, I end up staying 2 hours past end of day to wade through my inbasket and do clerical work that isn't even my clinic notes.

These are just my thoughts. I really think you should strongly consider starting your own private practice or joining academia. I think you’ll be disappointed elsewhere. Even jobs that claim to be staffed well usually trim costs eventually.

I see no value in RN’s in outpatient psych. They are 2x+ cost of a MA. In fact, you really don’t even need a MA in my state. Teaching someone to get vitals, relay messages, and schedule urgent appointments can be taught to any caring staff. Part of my clinic note explains what should be done in an emergency. We have already discussed it, and staff can find it in the chart. Even prior auth’s can be taught. I call fewer than 1 patient on average per week. Even in residency, a full clinic with 8 residents shared 1 nurse. She essentially helped refill non-controlled meds for 1 month, told patients to schedule in 1 month, and directed patients to the ER. We had to return calls as our staff wouldn’t do it in residency. No advanced training beyond calling in a Rx on our behalf was ever performed by our RN.

I do the forms and letters, but I bill for it. Either charge or require an office visit to do it. Don’t spend non-clinic time here unless paid. Nurses aren’t trained to create well scripted custom letters.

Any basic staff can do this care coordination, but you may be able to create a cheat sheet to avoid repetitive talks. On-site social worker is great, but this isn’t a priority for most outpatient psych clinics.

Write-up every staff that interrupts or refuses to do a task. If needed, I’d cancel a patient to do a support staff activity after multiple write-ups. Admin don’t understand gentle requests for more help. They do understand reduced productivity due to a failure of their system. If admin can’t provide assistance, I’d demand fewer patient hours to manage the other issues. Either admin will fix the problem, or I’d be terminated.

I agree that quality staff and support are highly important. Unfortunately few places will prioritize this as well as your own practice.

 

[calvnandhobbs68]

To be honest, both suck.

I mean job 2 isn't THAT bad depending on what q3 month call means above. Does it mean cover consults/phone calls for a week for that hospital or for a weekend? If it's just a weekend 4x a year, along with some phone coverage, that's not bad at all. Sure, could probably go make more money somewhere else but job 2 doesn't sound like a bad place to park for 4-5 years while figuring out if that's what you actually want to do long term (don't have to stay there forever).

Crappy support staff is a really really easy way to get burned out quickly. I agree with the post above that you have to essentially start writing people up/documenting egregious interactions but honestly you have to figure out if that's a fight you wanna actually fight. Office support staff can make your life suck (forwarding every call to your office, not scheduling patients correctly, not following up on any patient phone calls, etc) if they know you're messing with them while admin is trying to figure out what to do about them vs you. If this was a job you loved but the support staff was the only big issue, okay then maybe that's a battle you want to pick. That's not what it sounds like though and sounds like they have a problem retaining basically any staff (probably because they underpay them, so they end up getting crappy people to begin with), so it's gonna be quite a fight.

 

[allantois]

Why not refer patients to PCP if they need care coordination?

 

[meow1985]

These are just my thoughts. I really think you should strongly consider starting your own private practice or joining academia. I think you’ll be disappointed elsewhere. Even jobs that claim to be staffed well usually trim costs eventually.

I see no value in RN’s in outpatient psych. They are 2x+ cost of a MA. In fact, you really don’t even need a MA in my state. Teaching someone to get vitals, relay messages, and schedule urgent appointments can be taught to any caring staff. Part of my clinic note explains what should be done in an emergency. We have already discussed it, and staff can find it in the chart. Even prior auth’s can be taught. I call fewer than 1 patient on average per week. Even in residency, a full clinic with 8 residents shared 1 nurse. She essentially helped refill non-controlled meds for 1 month, told patients to schedule in 1 month, and directed patients to the ER. We had to return calls as our staff wouldn’t do it in residency. No advanced training beyond calling in a Rx on our behalf was ever performed by our RN.

I do the forms and letters, but I bill for it. Either charge or require an office visit to do it. Don’t spend non-clinic time here unless paid. Nurses aren’t trained to create well scripted custom letters.

Any basic staff can do this care coordination, but you may be able to create a cheat sheet to avoid repetitive talks. On-site social worker is great, but this isn’t a priority for most outpatient psych clinics.

Write-up every staff that interrupts or refuses to do a task. If needed, I’d cancel a patient to do a support staff activity after multiple write-ups. Admin don’t understand gentle requests for more help. They do understand reduced productivity due to a failure of their system. If admin can’t provide assistance, I’d demand fewer patient hours to manage the other issues. Either admin will fix the problem, or I’d be terminated.

I agree that quality staff and support are highly important. Unfortunately few places will prioritize this as well as your own practice.

Ok, I appreciate your opionion. And I respectfully disagree.

When my patient claims to be manic, I need the support staff to ask about the other symptoms of mania, duration, what they've taken or done for it so far, unsafe behaviors (NOT just SI/HI). I need them to listen for speech patterns. I also need them to look at my documentation, if any, to see if this is baseline or unsafe, because for some people "mania" is really behavioral/poor coping.

If someone claims a patient has altered mental status, I need the support staff to ask when they were last known well, screen for stroke signs and symptoms, what they may have taken, prescribed or not, have there been any unsafe behaviors (NOT just SI/HI) as a result of mental status, are they medically ill, etc.

Anything less than the above info and I need to call the patient myself, or spend my time instructing the staff to call back with those questions.

After info is gathered, I need the staff to send me a message with the right level of priority through the right channels (inbasket vs call/interdepartmental chat vs knock on my door). That is the definition of triage. Determine how urgent an issue is based on clinical reasoning. I do not think that can be adequately taught in an informal way.

This may be further too-high expectations but I also want to be able to speak to PCP's and review labs and workup at the click of a button. This is one advantage of being part of a large multi-specialty system, which both jobs are.

I guess I could make my current job better if I taught the support staff things, and I do when I can. But no one has enough time for anything, myself included. And all I have towards my current job is ill-will right now.

I didn't mention this, but job 2 is semi-academia. They have a community residency program attached to them, but teaching or supervising residents is not required.

 

[meow1985]

Why not refer patients to PCP if they need care coordination?

I try, but they do not always have a PCP. At times they have a PCP in another health system. Then that's a call I have to make, because my support staff are too busy.

 

[meow1985]

I mean job 2 isn't THAT bad depending on what q3 month call means above. Does it mean cover consults/phone calls for a week for that hospital or for a weekend? If it's just a weekend 4x a year, along with some phone coverage, that's not bad at all. Sure, could probably go make more money somewhere else but job 2 doesn't sound like a bad place to park for 4-5 years while figuring out if that's what you actually want to do long term (don't have to stay there forever).

Crappy support staff is a really really easy way to get burned out quickly. I agree with the post above that you have to essentially start writing people up/documenting egregious interactions but honestly you have to figure out if that's a fight you wanna actually fight. Office support staff can make your life suck (forwarding every call to your office, not scheduling patients correctly, not following up on any patient phone calls, etc) if they know you're messing with them while admin is trying to figure out what to do about them vs you. If this was a job you loved but the support staff was the only big issue, okay then maybe that's a battle you want to pick. That's not what it sounds like though and sounds like they have a problem retaining basically any staff (probably because they underpay them, so they end up getting crappy people to begin with), so it's gonna be quite a fight.

Q3 mos is weekend only call. You cover consults in the hospital (average 3 patients, may be 0-5), as well as calls to the crisis line, with nurses being first-line to deal with those calls.

Some of the support staff at the current job are good, and some are not, just like everyplace. Some are experienced but many are new. There are overall not enough of them so people get burned out. There have been some macro institutional issues that led to a major restructuring of the department and various growing pains, which is part of the reason for the turnover at all levels. But the support level and acuity mismatch is not new, from what I hear.

 

[Old&InTheWay]

When my patient claims to be manic, I need the support staff to ask about the other symptoms of mania, duration, what they've taken or done for it so far, unsafe behaviors (NOT just SI/HI). I need them to listen for speech patterns. I also need them to look at my documentation, if any, to see if this is baseline or unsafe, because for some people "mania" is really behavioral/poor coping.

If someone claims a patient has altered mental status, I need the support staff to ask when they were last known well, screen for stroke signs and symptoms, what they may have taken, prescribed or not, have there been any unsafe behaviors (NOT just SI/HI) as a result of mental status, are they medically ill, etc.

This level of assessment and decision-making seems more in line with what an APP might be able to do, not an RN. You're essentially asking them to gather a focused history (which takes more skill/knowledge than a complete history), do a mental status exam over the phone, and make an assessment of whether this is a true emergency. I think the best you could possibly expect would be having whoever takes the call ask a generic set of questions.

Also, it's not clear to me how someone reading your prior notes somehow saves you a phone call back to the patient.

I also have a hard time imagining any patient calling with "altered mental status" that I don't send to the emergency room for evaluation.

 

[TexasPhysician]

Ok, I appreciate your opionion. And I respectfully disagree.

When my patient claims to be manic, I need the support staff to ask about the other symptoms of mania, duration, what they've taken or done for it so far, unsafe behaviors (NOT just SI/HI). I need them to listen for speech patterns. I also need them to look at my documentation, if any, to see if this is baseline or unsafe, because for some people "mania" is really behavioral/poor coping.

If someone claims a patient has altered mental status, I need the support staff to ask when they were last known well, screen for stroke signs and symptoms, what they may have taken, prescribed or not, have there been any unsafe behaviors (NOT just SI/HI) as a result of mental status, are they medically ill, etc.

Anything less than the above info and I need to call the patient myself, or spend my time instructing the staff to call back with those questions.

After info is gathered, I need the staff to send me a message with the right level of priority through the right channels (inbasket vs call/interdepartmental chat vs knock on my door). That is the definition of triage. Determine how urgent an issue is based on clinical reasoning. I do not think that can be adequately taught in an informal way.

This may be further too-high expectations but I also want to be able to speak to PCP's and review labs and workup at the click of a button. This is one advantage of being part of a large multi-specialty system, which both jobs are.

I guess I could make my current job better if I taught the support staff things, and I do when I can. But no one has enough time for anything, myself included. And all I have towards my current job is ill-will right now.

I didn't mention this, but job 2 is semi-academia. They have a community residency program attached to them, but teaching or supervising residents is not required.

A RN is not trained to do those things. Even a NP isn’t trained to accurately do those things. You’ll need to train staff on all of this wherever you go, return the call yourself, train staff to schedule an urgent appointment that day, or direct to pcp-ER. Even if I had staff trained to semi-assess AMS, I’d expect staff to send to the ER or see me that day urgently. Even with training, I can’t see how the assessment over the phone wouldn’t need physician level of care to personally evaluate even if just to confirm.

If job 2 is academia, that is the closest you will get outside of starting your own practice.

 

[watto]

A RN is not trained to do those things. Even a NP isn’t trained to accurately do those things. You’ll need to train staff on all of this wherever you go, return the call yourself, train staff to schedule an urgent appointment that day, or direct to pcp-ER. Even if I had staff trained to semi-assess AMS, I’d expect staff to send to the ER or see me that day urgently. Even with training, I can’t see how the assessment over the phone wouldn’t need physician level of care to personally evaluate even if just to confirm.

If job 2 is academia, that is the closest you will get outside of starting your own practice.

It might be worth partnering with another detail-oriented psychiatrist in a small group practice, where you can share systems. Ideally, you might be able to get the blend of independence and support that you desire - while at the same time using the experience as another training opportunity to really suss out what type of system works for you.

 

[dl2dp2]

I actually kind of agree with that. I don't feel comfortable with starting my own private practice right now, and almost every job in the area is some variant of Job 2. The higher paying jobs are like 1 - they have something wrong with them from an infrastructure or resources standpoint.

You should just start your practice now part time. It's really not that hard.

 

[Monocles]

Drug seeking behavior and substance abuse patients are everywhere. It is even high in my suburban adolescent patients. That’s psychiatry.

Noooo this is not true!

OP I learned that substance use disorders are my "least forte" in adult residency (imagine a nerdy guy asking "how many uh... cannabises do you use"). In the past 2 years of fellowship I've seen less than 4 cases of primary substance use (cannabis only , nothing "hardcore") out of maybe 100+ kids and adolescents and maybe ONE potential case of drug "seeking". Maybe it's a geographical region of texas vs northeast but here in my area if you don't want to work w/ substances cases there are plenty of subspecialists who are more than happy to take them on.

(Sure there are teenagers who smoke but are also highly functional and once their depression/anxiety are under control I've found they cut back significantly)

 

[robellis]

Ok, I appreciate your opionion. And I respectfully disagree.

When my patient claims to be manic, I need the support staff to ask about the other symptoms of mania, duration, what they've taken or done for it so far, unsafe behaviors (NOT just SI/HI). I need them to listen for speech patterns. I also need them to look at my documentation, if any, to see if this is baseline or unsafe, because for some people "mania" is really behavioral/poor coping.

If someone claims a patient has altered mental status, I need the support staff to ask when they were last known well, screen for stroke signs and symptoms, what they may have taken, prescribed or not, have there been any unsafe behaviors (NOT just SI/HI) as a result of mental status, are they medically ill, etc.

Anything less than the above info and I need to call the patient myself, or spend my time instructing the staff to call back with those questions.

After info is gathered, I need the staff to send me a message with the right level of priority through the right channels (inbasket vs call/interdepartmental chat vs knock on my door). That is the definition of triage. Determine how urgent an issue is based on clinical reasoning. I do not think that can be adequately taught in an informal way.

This may be further too-high expectations but I also want to be able to speak to PCP's and review labs and workup at the click of a button. This is one advantage of being part of a large multi-specialty system, which both jobs are.

I guess I could make my current job better if I taught the support staff things, and I do when I can. But no one has enough time for anything, myself included. And all I have towards my current job is ill-will right now.

I didn't mention this, but job 2 is semi-academia. They have a community residency program attached to them, but teaching or supervising residents is not required.

At this point you’re expecting your support staff to be a PGY-3 psychiatry resident, I don’t think that’s fair..

 

[TexasPhysician]

Noooo this is not true!

OP I learned that substance use disorders are my "least forte" in adult residency (imagine a nerdy guy asking "how many uh... cannabises do you use"). In the past 2 years of fellowship I've seen less than 4 cases of primary substance use (cannabis only , nothing "hardcore") out of maybe 100+ kids and adolescents and maybe ONE potential case of drug "seeking". Maybe it's a geographical region of texas vs northeast but here in my area if you don't want to work w/ substances cases there are plenty of subspecialists who are more than happy to take them on.

(Sure there are teenagers who smoke but are also highly functional and once their depression/anxiety are under control I've found they cut back significantly)

We are probably arguing different things as marijuana use in teens is now about 30% in the last month across the USA. If you include 1 year, it’s 40%. Add alcohol, vaping, tobacco, etc. Assessing and treating substance use is a daily event for CAP anywhere. Even in my high functioning cash only practice. These kids also have mood and other related issues. If you are just saying that you have few Cannabis addiction in the absence of other psychiatric issues, I agree.

 

[Monocles]

We are probably arguing different things as marijuana use in teens is now about 30% in the last month across the USA. If you include 1 year, it’s 40%. Add alcohol, vaping, tobacco, etc. Assessing and treating substance use is a daily event for CAP anywhere. Even in my high functioning cash only practice. These kids also have mood and other related issues. If you are just saying that you have few Cannabis addiction in the absence of other psychiatric issues, I agree.

yes..? I agree with you too lol

EDIT: I guess to clarify my initial point - do I commonly talk to kids and teens about cutting back on their vaping etc etc? yes. Do I have polysubstance maladapted grown-ups w/ personality disorders and vast criminal histories coming to my office threatening to "put a bullet between [my] eyes" if I don't write them benzos? no. (thank god!)

 

[throw-away-go-away]

These are just my thoughts. I really think you should strongly consider starting your own private practice or joining academia. I think you’ll be disappointed elsewhere. Even jobs that claim to be staffed well usually trim costs eventually.

I see no value in RN’s in outpatient psych. They are 2x+ cost of a MA. In fact, you really don’t even need a MA in my state. Teaching someone to get vitals, relay messages, and schedule urgent appointments can be taught to any caring staff. Part of my clinic note explains what should be done in an emergency. We have already discussed it, and staff can find it in the chart. Even prior auth’s can be taught. I call fewer than 1 patient on average per week. Even in residency, a full clinic with 8 residents shared 1 nurse. She essentially helped refill non-controlled meds for 1 month, told patients to schedule in 1 month, and directed patients to the ER. We had to return calls as our staff wouldn’t do it in residency. No advanced training beyond calling in a Rx on our behalf was ever performed by our RN.

I do the forms and letters, but I bill for it. Either charge or require an office visit to do it. Don’t spend non-clinic time here unless paid. Nurses aren’t trained to create well scripted custom letters.

Any basic staff can do this care coordination, but you may be able to create a cheat sheet to avoid repetitive talks. On-site social worker is great, but this isn’t a priority for most outpatient psych clinics.

Write-up every staff that interrupts or refuses to do a task. If needed, I’d cancel a patient to do a support staff activity after multiple write-ups. Admin don’t understand gentle requests for more help. They do understand reduced productivity due to a failure of their system. If admin can’t provide assistance, I’d demand fewer patient hours to manage the other issues. Either admin will fix the problem, or I’d be terminated.

I agree that quality staff and support are highly important. Unfortunately few places will prioritize this as well as your own practice.

So in your example, let's say for a small group practice of 4 psychiatrists, what would the setup be?

I am assuming no RNs, but likely:
- front desk
- Medical Assistants/Techs -- but how many?
- with 4 docs, maybe an on site SW would be good as well as for counseling/therapy

 

[meow1985]

At this point you’re expecting your support staff to be a PGY-3 psychiatry resident, I don’t think that’s fair..

Ok, that's fair. I haven't worked with a lot of support staff so maybe I don't know what is "normal." FWIW I did have RN's do all of what I mentioned, but maybe those were exceptionally good RN's.

What I do know is that right now, is that I need something more than just a mention in passing that the patient "sounded weird" on the phone. I've had the clinical support staff return patient calls and gather literally no more info than the front desk person who has no clinical training.

 

[meow1985]

yes..? I agree with you too lol

EDIT: I guess to clarify my initial point - do I commonly talk to kids and teens about cutting back on their vaping etc etc? yes. Do I have polysubstance maladapted grown-ups w/ personality disorders and vast criminal histories coming to my office threatening to "put a bullet between [my] eyes" if I don't write them benzos? no. (thank god!)

I get a lot of the latter patient profile, but no threats of that caliber just yet. Knock on wood.

 

[Attending1985]

What does the extended evaluation process entail?

 

[allantois]

This level of assessment and decision-making seems more in line with what an APP might be able to do, not an RN. You're essentially asking them to gather a focused history (which takes more skill/knowledge than a complete history), do a mental status exam over the phone, and make an assessment of whether this is a true emergency. I think the best you could possibly expect would be having whoever takes the call ask a generic set of questions.

Also, it's not clear to me how someone reading your prior notes somehow saves you a phone call back to the patient.

I also have a hard time imagining any patient calling with "altered mental status" that I don't send to the emergency room for evaluation.

I am a psych PA. I don't even do these things. If patients require something more than to call in a short refill to their pharmacy, our support staff do not deal with these issues and patients have to make an appointment. It's a waste of time and money to have an APP or MD do these things outside of patient’s appointment time

 

[meow1985]

What does the extended evaluation process entail?

Your colleagues and support staff evaluate you, they look at your patient ratings, you get check ins with leadership every 3-6 mos for the first 2 years. Then if all is well you become full staff. If all is not well, you get a year to fix any issues. The docs I talked to at job 2 were barely aware the process was even happening to them when they were new, and no one seems to be worried about it, but it certainly makes my blood pressure go up.

 

[Mass Effect]

I am a psych PA. I don't even do these things. If patients require something more than to call in a short refill to their pharmacy, our support staff do not deal with these issues and patients have to make an appointment. It's a waste of time and money to have an APP or MD do these things outside of patient’s appointment time

That's one of the perks of private practice. Certainly not the case in community health centers or in my old academic job. There aren't enough appointments for everyone who's experiencing tearfulness to call and get an appt.

 

[Sushirolls]

Your colleagues and support staff evaluate you, they look at your patient ratings, you get check ins with leadership every 3-6 mos for the first 2 years. Then if all is well you become full staff. If all is not well, you get a year to fix any issues. The docs I talked to at job 2 were barely aware the process was even happening to them when they were new, and no one seems to be worried about it, but it certainly makes my blood pressure go up.

In my private practice I breathed a sigh of relief to no longer have to give a damn about these ridiculous mis-guided evaluations of admin, etc. They were reminiscent of medical school and less so residency.

Now, I just worry about delivering positive experience on what I would want for my own family, and striving to improve my counter transference with certain populations. Bad google or whatever reviews online irk me, but I don't respond to those. I focus more on helping my patients achieve symptom remission or their goal of functional improvement. I get a sincere thank you for helping make a difference, that's my eval. I get Christmas or other holiday card expressing gratitude that's my real eval. I have an employee who tells me they will follow me wherever I might move (only locally) the office too, that's my real eval. Patients who want you to treat their family members, too, that's a real eval.

I am the admin, and so far, my performance review as of today - I am doing a great job.

You can be the admin, too.

 

[erg923]

 

[Stagg737]

To be honest, both suck.

Second job actually sounds pretty reasonable at surface level. What makes it suck so much?

When my patient claims to be manic, I need the support staff to ask about the other symptoms of mania, duration, what they've taken or done for it so far, unsafe behaviors (NOT just SI/HI). I need them to listen for speech patterns. I also need them to look at my documentation, if any, to see if this is baseline or unsafe, because for some people "mania" is really behavioral/poor coping.

If someone claims a patient has altered mental status, I need the support staff to ask when they were last known well, screen for stroke signs and symptoms, what they may have taken, prescribed or not, have there been any unsafe behaviors (NOT just SI/HI) as a result of mental status, are they medically ill, etc.

Agree with others. If I get calls from these patients I don't even bother doing over-the-phone evals myself. They go straight to the ER for an actual eval. Too much liability and risk of missing something more serious by just screening over the phone.

Q3 mos is weekend only call. You cover consults in the hospital (average 3 patients, may be 0-5), as well as calls to the crisis line, with nurses being first-line to deal with those calls.

So one weekend every 3 months? If you really have to cover inpatient positions as an outpt employed doc, this seems pretty ideal.

Your colleagues and support staff evaluate you, they look at your patient ratings, you get check ins with leadership every 3-6 mos for the first 2 years. Then if all is well you become full staff. If all is not well, you get a year to fix any issues. The docs I talked to at job 2 were barely aware the process was even happening to them when they were new, and no one seems to be worried about it, but it certainly makes my blood pressure go up.

This sounds like an "are you competent enough to prescribe meds and not a complete a**hole" kind of eval. I wouldn't even give this a second thought. If it gets to the point that you're actually worrying about not being retained, it sounds like a crappy long-term job anyway and then you move on with more experience under your belt.

 

[the5thelement]

I would never sign a contract in which someone has a need to "evaluate" me for 2 years .Both of these jobs sound like a recipe for a burnout !

 

[ridethecliche]

Ok, I appreciate your opionion. And I respectfully disagree.

When my patient claims to be manic, I need the support staff to ask about the other symptoms of mania, duration, what they've taken or done for it so far, unsafe behaviors (NOT just SI/HI). I need them to listen for speech patterns. I also need them to look at my documentation, if any, to see if this is baseline or unsafe, because for some people "mania" is really behavioral/poor coping.

If someone claims a patient has altered mental status, I need the support staff to ask when they were last known well, screen for stroke signs and symptoms, what they may have taken, prescribed or not, have there been any unsafe behaviors (NOT just SI/HI) as a result of mental status, are they medically ill, etc.

I'm a PGY2 and all I can think reading this is how uncomfortable it would make me to be cross examined asking if I thought it was appropriate to have someone without a medical license come up with a differential that would then be used to guide triage... This is very different than a triage nurse at an ED eyeballing a patient... especially if you're expecting to do this over the phone.

I honestly didn't even know that this was a thing and all I think it does is give your tacit agreement that you're okay with your staff practicing outside their scope of practice.

I would never sign a contract in which someone has a need to "evaluate" me for 2 years .Both of these jobs sound like a recipe for a burnout !

All I could think about is how the head honcho there must be a psychodynamic minded person because everyones obviously being evaluated all the time anyway.

 

[deleted1100659]

OP, from someone who recently was in the job search there are great jobs out there, they come at various times and when you least expect it. Doccafe actually worked well for me, but I suggest make an email account just for that and phone number for it as well so you can ignore BS jobs. Ive seen some great jobs, and there were a few that paid really well and were reasonable work load and they were paying way above average due to the immediate need.

But im assuming you're around my age. You sound unfulfilled, burnt out, and just not happy. Life is too short to settle for that. Its very easy to get content with suffering or to justify it.