The State of Doctor-Patient Relations

[EmilKraepelin55]

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This is in small part a vent but largely is a concern of mine which has troubled me for quite some time. Now I am an incoming intern and I am incredibly excited to go head first into my psychiatric training. One of the primary reasons I chose this specialty is due to my interest in developing good long term relationships with my patients and to help guide them through their mental health treatment as an expert in their care. However, one thing I continue to notice is the degree to which long term patients criticize our apparent lack of knowledge and skill to be able to do this for them.

I have read countless anecdotes of patients from online forums who suggest that they never receive satisfactory answers, feel “gaslighted” by their psychiatrist, are never warned of the potential side effects of treatment, and state that they feel like Guinea pigs more than patients and so on. Many of these patients also seem to think that their personal research has been more than sufficient and that they could handle their own psychopharmacologic care better than we do and seem to disregard the amount of training and study we undergo ourselves in order to do what we do.

I am just curious of the opinion of the practicing psychiatrists on this forum about this sort of phenomenon. If you experience such mistrust from patients, then how do you set the record straight? How can we do better to ensure that we can instill trust in our patients and work as a team toward their mental health goals?

 

[wolfvgang22]

I see this a lot.
All I can do is my best and express my desire to help and educate.
Patients are welcome to manifest their autonomy and seek wellness elsewhere if that's not good enough for them, and I wish them luck. I'll still be here when that doesn't work out, happy to help.

 

[randomdoc1]

I felt similarly early on in training, even in medical school. Overtime you'll start to feel quite liberated of this burden. People will think what they want, no one or logic can change that but themselves. The events of the past 2 years made that quite clear. You know you're a good provider, studious, and take your work seriously. It's a silent majority that appreciates that. There is another wave of upset upon graduating residency too. You'll encounter a lot of drug seeking and patients overall demanding the wrong treatments be administered. You know it will be a lose lose. 1) they don't get better and 2) they often blame us. You learn to be ok with saying no. That may be the healthiest thing you do for patients in certain cases and it's much like raising a child. This dynamic has been discussed on this forum. I remember being in PP and the overwhelming majority wanted adderall and xanax on intake. When I don't prescribe it, they assault you online, leaving these very dishonest reviews, affecting your traffic. I've learned to screen intakes before they come in so neither of us waste our time. Many of these same patients overtime come around and develop mad respect for you! I remember a case of a bipolar I male, also with etoh and cocaine use but verified bipolar I. He was drug seeking with me too. Wouldn't take his meds, always doing drugs. His parents displaced their frustration on me and one day his attorney father came to an appointment guns blazing. I tactfully and assertively said it's not in my control what his son decides to do. These are the effective treatments that are offered. It's his responsibility to follow through. And if he continues his nonadherence, I won't put up with this anymore and will discharge him. To my surprise, his father said he respected that and before leaving made sure the entire balance was paid AND a credit for future visits. I was like WHOA! It's the ones who are just determined to not do the effective treatments who will feel the most dissatisfying.

Anyways, continue to practice good medicine. There are so many patients who will appreciate it. I'm 6 years out. Have a sizable practice. Over several psychologists. We have psychology students doing their practicum. I'm supervising residents and started to precept. The office has developed a reputation for one that focuses on EVIDENCE BASED CARE. We are not about quick fixes or saying things you want to hear. Some of the treatments may feel unpleasant but we ask the patient, are you here to get better or no?! It stands out from other private practices and the academic affiliation feels really great too. Just keep going. 🙂 I've sort of developed the reputation of being like a Judge Judy in psychiatry but hey, it's a style that works for me! No tolerance for bull, take it somewhere else!

 

[Bartelby]

A few thoughts.

1- For patients who chronically blame, criticize, and devalue interactions with you you should suspect personality pathology. If present, diagnose it and formulate an appropriate treatment plan. Often patients with, for instance, Borderline Personality Disorder may simply be told they have "depression," "anxiety," "PTSD" or even worse Bipolar disorder when the core issue is BPD. This leads to an understandable frustration with an insufficient treatment response. Explaining to such a patient what their diagnosis is and why their problems have been so chronic can lead to an "aha" moment that strengthens the treatment relationship and puts them on a road to gradual, hard-won gains.

2- Sometimes we need to engage our empathy and sit with patients who are frustrated with their outcomes. We can accomplish what the tools available to us allow us to accomplish. Sometimes the response to treatment is not as robust as we would hope. Being able to sit with the disappointment and help the patient understand what they can still realistically obtain from treatment is important, and that may start with acknowledging the reality of the limits of our state of knowledge.

3- Practice good medicine. You will hear about people doing 45-minute intake blocks, seeing 50 inpatients in a morning, stacking (or double booking) 15-minute follow ups all day, etc. When you imagine what that care must look like, it's no wonder the patients grumble. Find the quality of care you want to provide, and refuse to work anywhere that creates conditions that fall well short of that. We still live in the real world, and you have to work within constraints, but you can't be forced to practice below your own standard of care. Having a little time to actually speak with your patient does wonders for building rapport and providing "satisfactory" answers.

4- For those who "do their own research" remember that we educate and advise. They choose the treatment plan. We can praise the fact that they are trying hard to understand their own condition, while remaining gently steadfast about what the best treatment choices are and why. Maybe they don't come around to accepting your recommendations today, but as you continue to work with them and they start to trust you they may. If they are doing something outright dangerous, you will need to respond appropriately (which could even include termination). Otherwise, as others have said above you have to respect their autonomy, work with them to the extent they accept it, and try not to take it too personally!

Also keep in mind that online forums are NOT the real world! I have worked with populations that are typically deemed "difficult" in the ways you describe. I have found that the large majority are respectful, engage well with me, and take my advice seriously even if they end up not following it. The minority that regularly blame, externalize and complain are certainly there but don't let the outsized stress they can create mislead you into believing most patients present that way, because they simply don't.

 

[lockian]

This is in small part a vent but largely is a concern of mine which has troubled me for quite some time. Now I am an incoming intern and I am incredibly excited to go head first into my psychiatric training. One of the primary reasons I chose this specialty is due to my interest in developing good long term relationships with my patients and to help guide them through their mental health treatment as an expert in their care. However, one thing I continue to notice is the degree to which long term patients criticize our apparent lack of knowledge and skill to be able to do this for them.

I have read countless anecdotes of patients from online forums who suggest that they never receive satisfactory answers, feel “gaslighted” by their psychiatrist, are never warned of the potential side effects of treatment, and state that they feel like Guinea pigs more than patients and so on. Many of these patients also seem to think that their personal research has been more than sufficient and that they could handle their own psychopharmacologic care better than we do and seem to disregard the amount of training and study we undergo ourselves in order to do what we do.

I am just curious of the opinion of the practicing psychiatrists on this forum about this sort of phenomenon. If you experience such mistrust from patients, then how do you set the record straight? How can we do better to ensure that we can instill trust in our patients and work as a team toward their mental health goals?

I try to use affirmative statements. If they came in to fight, I display curiosity, ask them what they read, see if they can send it to me. It throws them off quite often. Also often, they don’t end up sending me anything at all. If they say something that’s blatantly wrong, “roll with resistance.” Pretend to consider it and say, “I know where that kind of idea may come from, and yet what we find is that what’s really going on is…”

I also may tell them, “you know your body, I know the science. So let’s work together.” I may also not talk about evidence or studies but rather patterns I’ve seen in my practice. It’s more down to earth and resonates better, though you have to know your audience.

Those patients can make you feel upset and discouraged and undermined, of course. I’ve been there. All kind of emotional responses are valid. After all, we are human too.

Also I’m a big believer in discussing side effects. People need to know what they put in their bodies. I can’t tell you how many people I met who didn’t know about SJS with lamotrigine or… I’ll just stop there.

 

[smalltownpsych]

I think the patients used to like psychiatrists a lot more when they practiced psychotherapy in addition to medication. The shift in the field over the last forty years to emphasize medication has devalued the relationship and the main aspect of your relationship with patients has often become in their perspective as a gatekeeeper, either for the right drug they need or to get out of the hospital. Mentioning Borderline PD, when you learn how to treat it with solid well thought out boundaries, these patients aren’t as bad as many in the field make them out to be. The worst patients are always going to be the substance users so learn to identify them quickly and learn MI skills so you don’t get sucked into their toxic relationship pattern where they have mastered the art of manipulation to attempt to get their needs met.

 

[hallowmann]

A few things:

1. Keep in mind that your job is not to make anyone do anything. Your job is to offer them treatment, using your knowledge to potentially improve their life. You might be able to affect how willing they are to receive that with appropriate psychotherapeutic skills, but in the end what they do is up to them.

2. Be humble. You know some things. They know others. No need to push through one thought. There is nothing wrong with entertaining/discussing their own fears or doubts about treatments, provided that it does not interfere with your evidence based recommendations for treatment. I constantly tell people that there is a lot we don't know, but what we can say is X. Every once and a while a patient might actually teach you something that is useful/beneficial (more often than you'd expect).

3. It's really easy (and financially rewarding) to be a terrible psychiatrist. I've seen people have 30 min intakes and 10-15 min follow-ups. I've seen them basically start whatever the patient wants, change meds almost every visit, never discuss diet/exercise/lifestyle, and rarely if ever discuss side effects. They then get paid the same for that 15 min follow-up as their colleague with the 40 min one. Half the people, even other docs, can barely tell the difference in level of care. When patients say their psychiatrist has never listened to them, sometimes it's true.

4. Boundaries are very important, both with your patient relationship and your own countertransference or bias. I have some very strong opinions/beliefs about certain things, but when I'm seeing a patient I am acutely aware of them and I try my best to make sure both my interaction and my perception of the person in front of me is not clouded by them. There is also a belief in my faith to give 70 excuses to my brother when I am wronged. As such I do not attribute to malice a patient's actions that could be explained by many other things. If someone is using tactics that may be viewed as manipulative, it's likely because it's been effective for them in the past as one of the few ways they can get what they need or navigate this world. They have likely been subject to it themselves, and it's important for the sake of boundaries that I respond in a way to model a healthy relationship/response to such tactics. If someone is trying to get a specific medication, it's often rooted in genuine pain or fear associated with withdrawal from that medication or simply pain associated with living life without it. I can empathize with this without harming them further by giving in and giving them the medication.

5. This is also a part of boundaries, but none of this is really personal, so don't take it as such. With this approach, I too have found that many "difficult" patients are only difficult to clinicians who can't separate themselves from the patient's pathology, and as a result their emotions become predictably entangled in them. People are just people, trying to survive in the life they've been given. Your responsibility is your actions and the use of your knowledge to treat people in an evidence-based manner.

 

[Candidate2017]

I am just curious of the opinion of the practicing psychiatrists on this forum about this sort of phenomenon. If you experience such mistrust from patients, then how do you set the record straight? How can we do better to ensure that we can instill trust in our patients and work as a team toward their mental health goals?

Patients take the leap of faith. Or they don't. There is trust or there isn't. Interestingly, no one mistrusts you or gives you bad reviews if you readily agree to their diagnoses of ADHD and anxiety and prescribe controlled substances.

I think the patients used to like psychiatrists a lot more when they practiced psychotherapy in addition to medication. The shift in the field over the last forty years to emphasize medication has devalued the relationship and the main aspect of your relationship with patients has often become in their perspective as a gatekeeeper, either for the right drug they need or to get out of the hospital.

It is not therapy that makes patients trust us, but trust that makes them take a leap of faith and endure therapy with us.

To be fair, old time psychiatrists carried a small panel and saw their patients every day or every week. And any patient who did not follow doctor's orders or could not engage in a therapeutic relationship would be sent to the asylum for an indefinite stay.

Nowadays, we see a larger swath of society (due to doctors' willingness to accept 3rd party payor money), including a portion of patients who would have spent a chunk of their lives in an asylum. Some of these patients do need to be in a controlled environment to detox, adhere to medications, have a routine, and partake in meaningful work. But society no longer tolerates or pays for that.

Also, many doctors don't practice with professional independence because they work for The Man. In this setting, the "customer" is always right because the main aspect of the doctor-patient relationship, in the eyes of The Man, is to collect insurance/Medicaid-care money. So you need "empathy" lest someone complain you are not "listening" to their need for controlled substances. The more this type of customer/business transaction is stressed, the less trust all patients have for doctors.

 

[lockian]

Patients take the leap of faith. Or they don't. There is trust or there isn't. Interestingly, no one mistrusts you or gives you bad reviews if you readily agree to their diagnoses of ADHD and anxiety and prescribe controlled substances.

Until your pill mill gets shut down or the board comes knocking.

I think it’s important to remember it takes two to build a relationship. There are things you can do such as spending time and explaining and validating. Even using open body language can predispose to trust. You can be down to earth and pleasant and folksy. But if the patient comes in with a determination to get a specific thing or with certain preconceptions, there is only so much you can do. A few bad reviews are not going to make or break anyone.

 

[EmilKraepelin55]

Thank you everybody for your very detailed and insightful comments in this matter. I guess a ton of my concern came from a place of desiring to feel valued for my future professional contributions. I have always cared a great deal about the opinions of others. although over the years this mentality has lessened considerably. I also certainly hope that I didn’t come across as thinking we know more than we actually do or that my patients can never teach me. My personal as well as professional goal is to always approach situations with an open and curious spirit. I am acutely aware of the lack of knowledge that I possess, and I hope to always remain humble in my assessment of others. But again, I greatly appreciate your advice as I approach July. This is all so very exciting, but like many others I am incredibly anxious. I just want to do the best that I can for my future patients and hopefully inculcate a positive view of this profession during my career despite its more mired history.

 

[smalltownpsych]

Patients take the leap of faith. Or they don't. There is trust or there isn't. Interestingly, no one mistrusts you or gives you bad reviews if you readily agree to their diagnoses of ADHD and anxiety and prescribe controlled substances.


It is not therapy that makes patients trust us, but trust that makes them take a leap of faith and endure therapy with us.

To be fair, old time psychiatrists carried a small panel and saw their patients every day or every week. And any patient who did not follow doctor's orders or could not engage in a therapeutic relationship would be sent to the asylum for an indefinite stay.

Nowadays, we see a larger swath of society (due to doctors' willingness to accept 3rd party payor money), including a portion of patients who would have spent a chunk of their lives in an asylum. Some of these patients do need to be in a controlled environment to detox, adhere to medications, have a routine, and partake in meaningful work. But society no longer tolerates or pays for that.

Also, many doctors don't practice with professional independence because they work for The Man. In this setting, the "customer" is always right because the main aspect of the doctor-patient relationship, in the eyes of The Man, is to collect insurance/Medicaid-care money. So you need "empathy" lest someone complain you are not "listening" to their need for controlled substances. The more this type of customer/business transaction is stressed, the less trust all patients have for doctors.

Just to be clear, psychiatrist doesn’t have to do psychotherapy to build better relationships, I was referring more to the skills set and awareness that experience and stance provides. Last psychiatrist I worked with did not do any “therapy”, but since he had been trained in family systems and intentionally sought out serious psychotherapy training in residency, he clearly knew the game. He always said it was back in the late 80s when psychopharmacology was taking over and the other residents would give him a hard time because psychotherapy would no longer be needed, it was all just brain chemistry.

 

[deleted1100659]

Thank you everybody for your very detailed and insightful comments in this matter. I guess a ton of my concern came from a place of desiring to feel valued for my future professional contributions. I have always cared a great deal about the opinions of others. although over the years this mentality has lessened considerably. I also certainly hope that I didn’t come across as thinking we know more than we actually do or that my patients can never teach me. My personal as well as professional goal is to always approach situations with an open and curious spirit. I am acutely aware of the lack of knowledge that I possess, and I hope to always remain humble in my assessment of others. But again, I greatly appreciate your advice as I approach July. This is all so very exciting, but like many others I am incredibly anxious. I just want to do the best that I can for my future patients and hopefully inculcate a positive view of this profession during my career despite its more mired history.

1. I always discuss my plan with the patient, I outline what to expect/when/and most common side effects. I explain why im choosing the medications im choosing.

2. Many times you will not be thanked, and depending on your setting you will experience a wide array of difficult people. The reality is many people won't get better, and this will burn you out at times, but you have to focus on those who you can help. For the ones who never get better, theres usually a reason why. Personality disorder, drug use, noncompliance, low insight, extreme circumstances, etc. You do your best to raise their insight, but there are limits. Sometimes you are even successful. However, you do help many people. The reward isnt their thank you; the reward is knowning that a 22 year old who was just discharged from an inpatient unit, floridly psychotic and on a stupid medication combination, gets 100x better after working with you and is now working 40 hours a week and potentially pursuing college (yes this is a real patient I was able to stabilize and help in the outpatient setting). When I saw him, he was manic, telling me how he could control nanites and would use them to discover the body's chemistry. Now he works 40 hours a week. He has some residual delusions, but doing great. I have several cases like that of people ive worked with and now very functional and doing well. My point is, you will help people in that way, you will give them some semblance of a normal life, hope for a future, but you will not help all people, and some may even blame you. This is inevitable. I always say that my prescribing isnt based on what the patient wants, its fundamentally based on what they need. And obviously, some patients will not like that when they come in wanting adderall/xanax.

 

[comp1]

If your only goal is to make people happy, psychiatry or any field of medicine may not be right for you. It's definitely not a "the customer is always right" sort of thing and it's why psychiatrists above all others are against referring to patients as consumers. A lot of patients come with significant trauma that has severely disturbed what would be considered typical societal expectations. As a psychiatrist, you train with this in the extreme, ie frank delusions and hallucinations, first in your training so that you can better spot and set guiding boundaries on it in more subtle cases. These sort of extreme experiences also build up a tolerance for people not being pleased with you that might be hard to get if you only dealt with people who post on forums in all of your training. I find that recognizing that patients are only a part of who you are out there to help is useful as well. You are there to support nurses, other physicians and social workers. You are ultimately a resource for society at large. This can help alleviate some of the need to be liked by every patient.

 

[EmilKraepelin55]

If your only goal is to make people happy, psychiatry or any field of medicine may not be right for you. It's definitely not a "the customer is always right" sort of thing and it's why psychiatrists above all others are against referring to patients as consumers. A lot of patients come with significant trauma that has severely disturbed what would be considered typical societal expectations. As a psychiatrist, you train with this in the extreme, ie frank delusions and hallucinations, first in your training so that you can better spot and set guiding boundaries on it in more subtle cases. These sort of extreme experiences also build up a tolerance for people not being pleased with you that might be hard to get if you only dealt with people who post on forums in all of your training. I find that recognizing that patients are only a part of who you are out there to help is useful as well. You are there to support nurses, other physicians and social workers. You are ultimately a resource for society at large. This can help alleviate some of the need to be liked by every patient.

I understand this, but I wouldn’t jump to the conclusion that I am a “people-pleaser” type. I’ve been on my fair share of psych rotations from inpatient to outpatient and C&L and have developed enough insight into psych specifically to know I can’t please everyone. My concern is more so regarding public perception of psychiatry and medicine as a whole. Yes, I did say that I am concerned about how people perceive my care offered to them but I have no delusions or expectation that they will even respect the dynamic. And as I have also stated, my idealistic view of the opinions of others has noticeably waned over the years with further experience and self-reflection. It’s sort of extreme to think I am not cut out for medicine based on such little information I have this provided about myself.

 

[comp1]

I think society has a pretty darn positive view of psychiatrists. I would even go so far as to say that in a lot of cases the public appears to significantly overestimate our ability to fix societal ills. Just take a look at California Governor Newsom's plans for Mental Health Courts. As far as medicine as a profession, 3/4 of people have a positive view of medical doctors. There aren't a lot of professions that rate so highly. Don't let comments' sections get you down!

 

[Sushirolls]

This is in small part a vent but largely is a concern of mine which has troubled me for quite some time. Now I am an incoming intern and I am incredibly excited to go head first into my psychiatric training. One of the primary reasons I chose this specialty is due to my interest in developing good long term relationships with my patients and to help guide them through their mental health treatment as an expert in their care. However, one thing I continue to notice is the degree to which long term patients criticize our apparent lack of knowledge and skill to be able to do this for them.

I have read countless anecdotes of patients from online forums who suggest that they never receive satisfactory answers, feel “gaslighted” by their psychiatrist, are never warned of the potential side effects of treatment, and state that they feel like Guinea pigs more than patients and so on. Many of these patients also seem to think that their personal research has been more than sufficient and that they could handle their own psychopharmacologic care better than we do and seem to disregard the amount of training and study we undergo ourselves in order to do what we do.

I am just curious of the opinion of the practicing psychiatrists on this forum about this sort of phenomenon. If you experience such mistrust from patients, then how do you set the record straight? How can we do better to ensure that we can instill trust in our patients and work as a team toward their mental health goals?

I have a bit of the opposite of some of the other posters above.

Its a slow erosion. Insurance eats away at you, getting letters from ChangeHealthcare. Negative Google reviews. People placing the Naturopaths on pedestals. Cannabis as the cure all. Therapists telling patients what they need med wise, or what their "real diagnosis" is and trying to drive the Psychiatric care. These days I know I've made a lot of positive impacts in people's lives and had a lot of people follow me from locations, yet still difficult to emphasize that. Ever rising tide of overhead expenses, and now the impending wave inflation - but being in a very regulated fixed healthcare economy - leaves little room for corresponding changes. I believe much of the Psychiatrist growth of income has come from "see more" or the 2021 insurance coding changes. But you can only see more for so long before that isn't enough to procure salary growth. Looking around and seeing the emphasis and growth of ARNPs that will ultimately inherit medicine, its just sad and tragic. It gets old fast, navigating the "no you don't have bipolar" and "how do I say this, but your ARNP didn't know what they were doing." Trying to continue to be the professional to meet patients where they are, and navigating their views, understanding, and "research" they've done to ultimately help them to their goals. There certainly is a decline in the respect of the profession - further evidenced by how many people get services and then ghost and don't pay for those services.

I keep eyeing the fence, and am looking to how I can transition from medicine to ranching. Many times I would literally rather shovel animal scat, and the times I am with my personal life hobbies, I actually feel very fulfilled and accomplished.

I've set up my current private practice to be way on the favorable end of stress reduction and less intense patient population, but even at that, I can't recommend people to go into medicine, and I'm eyeballing an exit.

Currently might be making a location change, and with that possible acquisition of notable acreage - the dream of being a rancher with it as source of primary income is quite exciting.

 

[erg923]

This is in small part a vent but largely is a concern of mine which has troubled me for quite some time. Now I am an incoming intern and I am incredibly excited to go head first into my psychiatric training. One of the primary reasons I chose this specialty is due to my interest in developing good long term relationships with my patients and to help guide them through their mental health treatment as an expert in their care. However, one thing I continue to notice is the degree to which long term patients criticize our apparent lack of knowledge and skill to be able to do this for them.

I have read countless anecdotes of patients from online forums who suggest that they never receive satisfactory answers, feel “gaslighted” by their psychiatrist, are never warned of the potential side effects of treatment, and state that they feel like Guinea pigs more than patients and so on. Many of these patients also seem to think that their personal research has been more than sufficient and that they could handle their own psychopharmacologic care better than we do and seem to disregard the amount of training and study we undergo ourselves in order to do what we do.

I am just curious of the opinion of the practicing psychiatrists on this forum about this sort of phenomenon. If you experience such mistrust from patients, then how do you set the record straight? How can we do better to ensure that we can instill trust in our patients and work as a team toward their mental health goals?

I understand this, but I wouldn’t jump to the conclusion that I am a “people-pleaser” type. I’ve been on my fair share of psych rotations from inpatient to outpatient and C&L and have developed enough insight into psych specifically to know I can’t please everyone. My concern is more so regarding public perception of psychiatry and medicine as a whole. Yes, I did say that I am concerned about how people perceive my care offered to them but I have no delusions or expectation that they will even respect the dynamic. And as I have also stated, my idealistic view of the opinions of others has noticeably waned over the years with further experience and self-reflection. It’s sort of extreme to think I am not cut out for medicine based on such little information I have this provided about myself.

It's not like the internet to freak out about something small and stupid or something they don't fully understand, is it??? First I've heard of this. 🙂

Comments sections on the interwebs are NOT representative of.... anything. There are some people who think the earth is flat, apparently. So, I mean...come on!

That said, clinical psychiatry is an easy job to do relatively poorly and/or quickly, and quite challenging to do full-time, day-after-day, patient after patient. Some of this is the nature of the work, and some is institutional/employer limitations based on factors such as reimbursement, patient demands, access demands, and limited social work support. I also agree that there is a significant element of overestimating how much psychiatric medicine can really help in the face of the other obvious and overwhelming factors (e.g., poverty, incarceration, materialism, natural narcissistic traits/tendencies, envy, sloth, repeated trauma and invalidation) that are involved in the experience of human suffering.

 

[Merovinge]

Its a slow erosion. Insurance eats away at you, getting letters from ChangeHealthcare. Negative Google reviews. People placing the Naturopaths on pedestals. Cannabis as the cure all. Therapists telling patients what they need med wise, or what their "real diagnosis" is and trying to drive the Psychiatric care. These days I know I've made a lot of positive impacts in people's lives and had a lot of people follow me from locations, yet still difficult to emphasize that. Ever rising tide of overhead expenses, and now the impending wave inflation - but being in a very regulated fixed healthcare economy - leaves little room for corresponding changes. I believe much of the Psychiatrist growth of income has come from "see more" or the 2021 insurance coding changes. But you can only see more for so long before that isn't enough to procure salary growth. Looking around and seeing the emphasis and growth of ARNPs that will ultimately inherit medicine, its just sad and tragic. It gets old fast, navigating the "no you don't have bipolar" and "how do I say this, but your ARNP didn't know what they were doing." Trying to continue to be the professional to meet patients where they are, and navigating their views, understanding, and "research" they've done to ultimately help them to their goals. There certainly is a decline in the respect of the profession - further evidenced by how many people get services and then ghost and don't pay for those services.

So I agree with almost all the ills you discuss here, and I see them on a regular basis as well. There are innumerable small erosion spots around the practice of medicine that have dramatically accelerated in recent years.

Here's the flip side though. MDs remain one of the top handful of most trusted professions on Earth despite the above changes. We make a very respectable salary working reasonable hours (particularly in psychiatry). You don't need growth when you can work good hours and take home $300k/year. If that doesn't satisfy a person whos hedonic treadmill was wired for IB or corporate law, then it's time to get into startups or do something other than clinical medicine. You get to leave work knowing you made a difference. I don't need to volunteer or fill in any gaps in my life because my daily job is service to people from all walks of life and I sleep oh so good at night. When I have a particularly stressful life event occurring, going to work makes me feel better because of the prosocial nature of the work. I never have to worry about being a rent-seeking (economic term for those not familiar) sycophant on society and I still vacation in Hawaii, Bora Bora, the USVI's, or soon to be the Maldives at 5 star resorts.

 

[splik]

I have read countless anecdotes of patients from online forums who suggest that they never receive satisfactory answers, feel “gaslighted” by their psychiatrist, are never warned of the potential side effects of treatment, and state that they feel like Guinea pigs more than patients and so on. Many of these patients also seem to think that their personal research has been more than sufficient and that they could handle their own psychopharmacologic care better than we do and seem to disregard the amount of training and study we undergo ourselves in order to do what we do.

I am sure there are huge variations nationally and also depending on setting. But yes, unfortunately there are a lot of psychiatrists out there who aren't interested in really working with their patients, are not competent, or work in systems that value volume over quality. i had the same concerns you did as a resident and I used this as motivation to try to provide the best care I possibly could and learn as much as I can. I could make a lot more money if I prioritized volume over relationships but that kind of model just does not appeal to me. That said, it is important to remember that some patients will just never be satisfied. Often it is the patients we work hardest for that appreciate us the least and devalue us the most. I am highly selective about who I see in the outpatient setting. They have to want to see me and be motivated. Such patients are few and far between in residency programs but there are many of those patients who are appreciative of what we have to offer in the real world. And I don't screen out patients by pathology so lots of my pts do have comorbid personality disorders, substance use disorders, and forensic histories (I see a disproportionate number of pts with serious violence histories including homicide for some reason) etc but they are still interested in treatment and capable of benefiting from it.

 

[deleted1100659]

I have a bit of the opposite of some of the other posters above.

IPeople placing the Naturopaths on pedestals. Cannabis as the cure all. Therapists telling patients what they need med wise, or what their "real diagnosis" is and trying to drive the Psychiatric care.

x1million.

Im finishing out this community psych outpatient gig and it has been soul crushing many days. This morning (not even counting the afternoon) I have 10 people scheduled with me, in 20 min slots. All high acuity. Over half ive never seen before, they just have a random two sentence note from a CSU or something because they're a "discharge f/u" yet ive never seen them. Most with multiple medications, medical conditions, drug use, etc. Often they arrive late and my appt time ends up being around 10 mins for the patient. 10 minutes to see someone youve never seen before and figure out what they need. Someone who is usually a poor historian. Then they try to cut costs in community psych and put as many midlevels under you as possible, yet they rake in tons of money from govt funds. That money is going somewhere...but on the bright side ill be starting my next attending job soon, so I figure nowhere to go but up, lol

 

[randomdoc1]

Brethren, we need to do more private practice! That's where we have our voice. At first it's a financial investment (but play smart and it ends up being quite lucrative AND you get to be a high quality physician, win win). You get the freedom to practice good medicine and the vast majority of us will find a sizable following. It's so rewarding. Overtime, your patient panel will evolve to one that you work well with AND they make progress. Patients generally like things that work. Then bring on more colleagues and that's how we band together away from the chaos of hospital systems, greedy middle men, and abusive health insurance contracts. You find growing power in numbers, especially when it's comprised of high quality providers that people seek far and wide for.

 

[Bartelby]

x1million.

Im finishing out this community psych outpatient gig and it has been soul crushing many days. This morning (not even counting the afternoon) I have 10 people scheduled with me, in 20 min slots. All high acuity. Over half ive never seen before, they just have a random two sentence note from a CSU or something because they're a "discharge f/u" yet ive never seen them. Most with multiple medications, medical conditions, drug use, etc. Often they arrive late and my appt time ends up being around 10 mins for the patient. 10 minutes to see someone youve never seen before and figure out what they need. Someone who is usually a poor historian. Then they try to cut costs in community psych and put as many midlevels under you as possible, yet they rake in tons of money from govt funds. That money is going somewhere...but on the bright side ill be starting my next attending job soon, so I figure nowhere to go but up, lol

Congrats on leaving! If that is a typical day that is one of the worst psychiatry jobs I have ever heard of!

 

[smalltownpsych]

Brethren, we need to do more private practice! That's where we have our voice. At first it's a financial investment (but play smart and it ends up being quite lucrative AND you get to be a high quality physician, win win). You get the freedom to practice good medicine and the vast majority of us will find a sizable following. It's so rewarding. Overtime, your patient panel will evolve to one that you work well with AND they make progress. Patients generally like things that work. Then bring on more colleagues and that's how we band together away from the chaos of hospital systems, greedy middle men, and abusive health insurance contracts. You find growing power in numbers, especially when it's comprised of high quality providers that people seek far and wide for.

Team up with solid psychologists and you will be happier and vice versa. If I could get a psychiatrist to relocate to beautiful Northern Idaho, I have an office that is available for a potential gold mine.

 

[deleted1100659]

Congrats on leaving! If that is a typical day that is one of the worst psychiatry jobs I have ever heard of!

thanks! found an outpatient job affiliated with a major hospital system, they use epic (300x better than my current EMR here) and seem to have more structure. Area is also nice.

but yep usually 3-4 days out of the week it was like that, maybe 1-2 i get lucky with a lot of no shows.

In a way I dont regret this job, because I gained a vast exposure to all of the newer medications because we utilize the patient support programs here quite frequently so I feel well versed in vraylar, caplyta, most LAis, etc.

Also I learned to ask more questions about the job and get specifics. If its community healthcare, they are probably hurting for physicians so use that for negotiating power if I ever go back to that style of settting...

 

[deleted1100659]

Brethren, we need to do more private practice! That's where we have our voice. At first it's a financial investment (but play smart and it ends up being quite lucrative AND you get to be a high quality physician, win win). You get the freedom to practice good medicine and the vast majority of us will find a sizable following. It's so rewarding. Overtime, your patient panel will evolve to one that you work well with AND they make progress. Patients generally like things that work. Then bring on more colleagues and that's how we band together away from the chaos of hospital systems, greedy middle men, and abusive health insurance contracts. You find growing power in numbers, especially when it's comprised of high quality providers that people seek far and wide for.

we need to form a secret society of SDN psychiatrists who "fight the system" that screws us over and patients over. In all seriousness though, I do wish there was more representation from our side

 

[Sushirolls]

Sadly the numbers that follow the PP path won't ever be enough to tip the scales. Some people just aren't meant to run a practice, nor want to. Then you have the sea of ARNPs that are rising. No unified force will ever mount.
Courts continue to side in favor of UHC/UMR/Optum (or over turn cases that went against them), or pass things that sound good like the 'no surprises act' which is wrapped gift to the insurance companies.

I really don't foresee any large wide scale viable solutions to the future.

 

[randomdoc1]

Sadly the numbers that follow the PP path won't ever be enough to tip the scales. Some people just aren't meant to run a practice, nor want to. Then you have the sea of ARNPs that are rising. No unified force will ever mount.
Courts continue to side in favor of UHC/UMR/Optum (or over turn cases that went against them), or pass things that sound good like the 'no surprises act' which is wrapped gift to the insurance companies.

I really don't foresee any large wide scale viable solutions to the future.

I did find the ninth circuit incident to be very sus. Don't know how, but UHC is definitely involved. They're so gross. Maybe not everyone's designed for PP but at least the ones who may not be a fit to run one, can still work for one (maybe a side gig? try it out?). We're ever so slowly...backing away from UHC. Getting more full with other insurances and getting paneled on more. UHC calls the office ALOT now looking for a prescriber and we smugly say we're quite full atm. Plan to use the network deficiency as a bargaining chip. Had two successful fee schedule increases so far. There's always a way to exert some influence, at least for bettering your own quality of life and those around you. btw, this clinic NEVER offers UHC as a health insurance. Yea, it's cheaper from a premium standpoint for both employer and employee with one of the biggest networks of providers. But it's such a gamble, UHC is so notorious for making it hard to access services that are outside of routine/maintenance often leaving patients with a massive and perhaps bankrupting tab. Would never subject the employees to that kind of gamble. Plus, don't want to be a customer to something so icky too.

The PP versus other paths. It never ceases to amaze me how many MH providers choose a non-PP path in part due to anxiety about financial security. Way I see it, you try PP, if it does not work you go back to the gigs you had before, that's the worse that could happen (so you're already there). Or the other option is to stay at the non-PP gigs and never know how you would have done.

 

[Desired Member]

Sadly the numbers that follow the PP path won't ever be enough to tip the scales. Some people just aren't meant to run a practice, nor want to. Then you have the sea of ARNPs that are rising. No unified force will ever mount.
Courts continue to side in favor of UHC/UMR/Optum (or over turn cases that went against them), or pass things that sound good like the 'no surprises act' which is wrapped gift to the insurance companies.

I really don't foresee any large wide scale viable solutions to the future.

I plan to NEVER oversee any midlevels, demand 1.5 hour initial intake appointments and 30 minute follow ups, and only work 3 days per week or less. I don't care if I don't make much money. But I really don't think I can handle the stress of running my own business. I really hope this plan works out LOL

 

[smalltownpsych]

I plan to NEVER oversee any midlevels, demand 1.5 hour initial intake appointments and 30 minute follow ups, and only work 3 days per week or less. I don't care if I don't make much money. But I really don't think I can handle the stress of running my own business. I really hope this plan works out LOL

Sounds like a doable plan to me and Im already running the business. 😜

 

[littlefred]

I plan to NEVER oversee any midlevels, demand 1.5 hour initial intake appointments and 30 minute follow ups, and only work 3 days per week or less. I don't care if I don't make much money. But I really don't think I can handle the stress of running my own business. I really hope this plan works out LOL

Same here, working 3 days a week is where it's at!

 

[painballer27]

Same here, working 3 days a week is where it's at!

How much are you making?

 

[littlefred]

How much are you making?

Sent you a private conversation.

 

[calvnandhobbs68]

I plan to NEVER oversee any midlevels, demand 1.5 hour initial intake appointments and 30 minute follow ups, and only work 3 days per week or less. I don't care if I don't make much money. But I really don't think I can handle the stress of running my own business. I really hope this plan works out LOL

This is very very doable. I've told people this before (and this seems to work for child/adolescent where you really pretty much always need 90 minutes for an intake) but one way to make this financially viable if you're on your own or getting paid by percentage is for intakes is to split a 90 minute intake into a 60min intake and 30min followup in about 7-10 days. It requires you to have the f/u openings but then you can bill a 99205 intake and 99214 +/- 90833 followup. Have not had a problem with this with insurance in about a year of doing it this way. You can easily justify the 60min intake on time to gather the history and then followup for discussing and initiating treatment planning.

 

[FlowRate]

I've learned to screen intakes before they come in so neither of us waste our time.

I was considering making a separate thread/post about this--I'd be really interested to hear more about what's worked for you so far regarding screening. Do you have a relatively set group of questions? About how long do you usually spend? Do you schedule that screening call?

 

[deleted1100659]

Sent you a private conversation.

also curious, lol

Would love to go to part time once my debt is paid and I have a little more savings..

 

[Merovinge]

This is very very doable. I've told people this before (and this seems to work for child/adolescent where you really pretty much always need 90 minutes for an intake) but one way to make this financially viable if you're on your own or getting paid by percentage is for intakes is to split a 90 minute intake into a 60min intake and 30min followup in about 7-10 days. It requires you to have the f/u openings but then you can bill a 99205 intake and 99214 +/- 90833 followup. Have not had a problem with this with insurance in about a year of doing it this way. You can easily justify the 60min intake on time to gather the history and then followup for discussing and initiating treatment planning.

Absolutely, this is an ideal way to get paid for the doing the right thing for the patient. Can even book both appointments together with the initial 60 min block, gets the patient time to gather any collateral you need as well during that one week break.

 

[ObsequiousAplomb]

Sent you a private conversation.

I'm also very curious

 

[randomdoc1]

I was considering making a separate thread/post about this--I'd be really interested to hear more about what's worked for you so far regarding screening. Do you have a relatively set group of questions? About how long do you usually spend? Do you schedule that screening call?

Here's my triage breakdown--

1)Some right off the bat whether you've talked to them or not, you can tell will not be a fit. I refer them to other offices.

2)For the prospective ones, whether I'm interacting directly with them or someone is answering the phone we ask:
a.what's bringing you in?We can talk about symptoms, recent events, prior diagnoses or possible diagnoses, what meds are we currently on (savvier people conveniently leave out the benzos, opiates, and stims)
b.what treatment history have you had if any? They can include outpatient care like therapy and med management, PHP, IOP, inpatient (and I ask how many stays and when was the most recent)
c.Is there anything taking place that is a major mental health crisis that would benefit from referral to higher level of care? Such as high substance use, SI, HI, etc.
d.Name, DOB, name of insurance and member ID (to make sure I'm in network and you can see if their insurance has a high deductible so you can warn them)

If it looks like it'll work out, I get them scheduled (after screening everyone on the drug database of course). If something looks like it won't work, I often tell them I'll check their insurance info, the availability, and get back to them. I get an email address too. This sounds terrible, but I avoid having a live conversation about why they cannot be seen as a new patient. I just send an email or go directly to voicemail with other referrals and say there is not availability at the moment. The reason I do this is because it's so hard to find an actual psychiatrist, people will beg (for both good and bad reasons). Those about to run out of controlled substance get very agitated. Axis II tries to keep you on the phone forever. Just a couple examples of many. Patient must call themselves to schedule their intake, don't accept family/friends calling for a patient as it heralds high risk of non-adherence/unwillingness to engage in treatment.

I try to get staff to gather the needed info. Sometimes I call the patient if I need a bit more.

The patients I work the best with tend to have the following characteristics in this process:
-know their insurance info and understand what a deductible means! (when someone really struggles with this, you know money will be an issue and there's already a sense of chaos in their life)
-stable employment (their insurance policy often discloses name of employer and how long they had the policy)
-good historians, good details, readily know what they are looking to accomplish
-responsive to communication
-generally have respectful mannerisms/tone
-follows instructions well

Features that can raise an eyebrow (not necessarily deal breaker but....):
-getting caught on the drug database (even worse if patient was caught in a flat out lie)
-fired from multiple providers
-the patient has basically lived the past 12+ months in PHP/IOP
-they are on a *&^% ton of pills
-bad gut feeling
-already difficult to office staff
-person calls multiple times requesting the same provider despite being told multiple times there is no availability (once had a patient do this despite I myself telling the patient I'll likely not take new long term patients, potentially for the rest of my career)
-person sounds very confused, lots of mistakes, seems forgetful (heavy AODA? Will they be regularly missing appointments?)
-person asking to speak to the clinic owner/manager or other forms of boundary challenging
-person sounds too familiar with the healthcare system, terminology, meds
-someone emailing you a whole novel about their life
-referral from another psychiatrist/prescriber
-referral from a place that historically gave you bad referrals lol
-urgent/stat referrals from a major healthcare system (one turned out to be severe etoh use disorder, benzo use disorder, on serious benzos, not doing well with benzo taper)

 

[Alemo]

Here's my triage breakdown--

This all sounds eerily similar to dating standards, picking out a nanny, selecting a dog breeder….

 

[randomdoc1]

This all sounds eerily similar to dating standards, picking out a nanny, selecting a dog breeder….

Well yea, you gotta both hit like to match LOL.