To Those of You Who Practice in the Indigent Outpatient World

[clement]

I joined an outpatient clinic which despite being a setting with many indigent/uninsured patients, has extremely limited access to case management and even nursing for that matter.

I also live in a vary populous state where revolving door psychiatric care is more common due funding issues. Take your guesses.

Getting people linked with ACT takes upwards of six months etc. So when I joined, the plan was for me to take on the "neutral" (mixed bag) caseload of someone who'd left. Instead, I have inherited that caseload plus those who still practice w/ me were allowed to transfer 30-50 of their cases to my load. You guessed it.

They're shipping over their sickest SMI cases that require polypharmacy to maintain stabilty (i.e. 3+ antipsychotics, 2+ mood stabilizer, no labs in nearly a decade)... and some of their sickest borderlines (which I prefer to former). This SMI population isn't a hugely prevalent in our practice, but it's who they're transferring over.

Aside from not having managed this population in the outpatient setting with bare bones nursing in nearly a decade, no one wants to be the new psychiatrist getting the toughest of everyone else's case load. When I brought it up to leadership, I was told, "We have some tough cases. Sometimes they get symptomatic. Sometimes they get hospitalized."

I thought the goal of tx in the outpatient setting was to prevent hospitalization and not play musical chairs with liability. Shifting pts from caseload to caseload when opportune isn't helping such patients (seriously, some havent had a BMI recorded in nearly a decade). The excuse is that, "they need to be seen sooner and you have time since your load is still small."

How have others joining a clinic as the newest member handled this? Some of these pts are the damned if you do, damned if you don't variety...Liability if you keep prescribing, and liability based on a hx of violence and SA's if you don't.

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[Celexa]

Do I have this right, you inherited a full case load AND everyone else was allowed to transfer their worse cases to you? Gee, I wonder why the last person quit.

Honestly it sounds like a lot of very good reasons to also quit and find a job somewhere else.

 

[When is graduation again?]

Do I have this right, you inherited a full case load AND everyone else was allowed to transfer their worse cases to you? Gee, I wonder why the last person quit.

Honestly it sounds like a lot of very good reasons to also quit and find a job somewhere else.

I agree. If you're serious enough, you could probably threaten to leave if they don't reduce your SMI load. Unless there are no other jobs in your area, you have a bit of leverage. If they won't budge, it's better to leave now than after the patient's start depending on you, since there's less guilt.

Practically speaking though, having SMI patients in a standard outpatient clinic might not be so bad, if they are the type to no-show appointments. I have a a few treatment non-engaged patients, but since I'm ACT, I have to keep trying to track them down. There's nothing worse than having to track down someone who is high risk and doesn't want to engage... it's not fun for safety or morale.

 

[Bartelby]

I would try to confirm that you are really getting others' problem cases + a full caseload. If so I would start aggressively looking for another job. Such behavior speaks volumes about both the administration and the colleagues you will have to work with in that role.

 

[clement]

Do I have this right, you inherited a full case load AND everyone else was allowed to transfer their worse cases to you? Gee, I wonder why the last person quit.

Honestly it sounds like a lot of very good reasons to also quit and find a job somewhere else.

Yes, you understood correctly. The other person's case load was already distributed among doctors still in clinic, notably. However I'm getting those pts PLUS some very clear dumps of pts that don't originate from the departed doctor's case load. Being the new person, I felt pressure to keep my mouth shut at first. Thankfully most of us are at least union members. There are other gigs in the area but nothing as geographically convenient.

The preliminary response has been that they generally have SMI pts in clinics. They do, but the prevalence is not as high as the number transferred to me suggests. Maybe once upon a time they had a lot and they got passed down generations of doctors. My argument is when I do new intakes, they're nowhere nearly as sick or complex as those I'm getting as transfers. Which proves that the ones I'm getting from colleagues active in clinic are the pts they don't want in their caseload.

The worst part is that the last note on these pts doesn't tell the whole story (med trials as one thing). So getting a pt who is both new to me and an SMI pt is not an attractive combo to face until my case load builds.

Many are stable SMI cases, but ticking time bombs of liability. I mean, if I had 300 pts and I had the chance to transfer out 50, of course I'm going to hold on to the most straightforward cases. Let's face it, when we get pts from other psychiatrists (as opposed to SWer therapists, psychologists, etc), they tend to be those cases most people don't want.

I've asked them to provide me with details of criteria they used to transfer pts from other doctors' loads. I'm sure they'll say, "They are pts that need to be seen sooner and your load is light." Sure, but these SMI's are stably noncompliant train wrecks who slid by w/ being seen every 3 months. At some point, they'll be a huge liability and they seem to not want it on their watch. Increasing the frequency of contact by transferring from one case load to another isn't a substitution for the kind of infrastructure needed to manage SMI pts.

I probably should have been a little suspicious during my first days on the job when one of the psychiatrists said, "I have a Clozaril pt I want to transfer to you." Fine, give me the Clozaril case over the triple antipsychotic Socratic Oath fail on loads of Methadone with hyperthyroidism that hasn't seen a PCP in years, has no recent labs, or gotten an EKG.

 

[Stagg737]

The patients you’re complaining about actually don’t sound that bad, they sound like typical CMHC patients. I’d take many of those patients over a panel of severe borderlines at a CMHC any day (and yes, I worked with all of them).

The part that sounds awful is how they transferred patients to you and filled your panel. Sounds like a the entire clinic is full of burnt out workers looking to pass the buck. Agree with others that this just sounds awful from that perspective and I’d run.

 

[Merovinge]

Hazing the new guy is unfortunately so in-built into medicine that some times it appears to happen without conscious thought, although I suspect this is very deliberate. When my wife started as the new partner at a practice they assigned her every single holiday of call for the entire year (on a q4 call system). I think some folks are intentionally looking to see if you will be a new doormat to walk over or not, obviously your life circumstances decide how you respond.

 

[annoyedpsychiatrist]

How have others joining a clinic as the newest member handled this? Some of these pts are the damned if you do, damned if you don't variety...Liability if you keep prescribing, and liability based on a hx of violence and SA's if you don't.

i left.

The liability isnt as bad as you think just because youd be judged on the standard of care in that setting and for patients in the community health setting that is not unusual. That said, its still scary because you never know. But even with the richer population, they may be more aggressive legally because they have more means/cunning.

The violence risk can certain be unnerving as i was almost attacked multiple times in my last job. Hopefully you're a sizeable male. I am somewhat built, and I think that helps as a deterrent. Still I was worried about getting shot or stabbed in my last job. I dont worry about that as much now which is nice.

at my current job we see community health style patients to a slightly lesser degree. Can still be quite stressful. Lots of drugseeking and then they get a patient review form to fill out which is lovely..still, has its pros too.

Places like the one you're describing arent meant to keep people long term.

 

[Celexa]

Hazing the new guy is unfortunately so in-built into medicine that some times it appears to happen without conscious thought, although I suspect this is very deliberate. When my wife started as the new partner at a practice they assigned her every single holiday of call for the entire year (on a q4 call system). I think some folks are intentionally looking to see if you will be a new doormat to walk over or not, obviously your life circumstances decide how you respond.

I agree I think the only good choices for the OP here are to aggressively push back (backed by the real threat of leaving) or actually leave. Otherwise, they're setting up to be the clinics whipping boy.

One way I like to think about this is that institions can have a version of personality disorder. What's the treatment for personality disorders generally? Structure, boundaries, and limits. Appeasement does not work, neither does ignoring it and hoping it gets better on its own.

 

[TheRightMedication]

Have you tried asking telling them you'll be taking hour long blocks for each transfer to deal with the complexity of it appropriately?

Hopefully your contract has some language about being provided appropriate staff, facilities, time, ect. to practice medicine in keeping with the standards of the profession.

I think we all underestimate our power to tell people how it's gonna be, especially if you embrace the clinical situation - "I'm very excited for the opportunity to care for this sick population, and here are my recommendations about how this can happen safely and efficiently."

If a doctor says "it has to be this way for good care / safety" and admin says no, that's a big deal and it gives you a ton of leverage as the emails pile up.

You would have to plan around not working there anymore, of course.

 

[clement]

The point about hazing is of course pervasive in both medical training culture and its aftermath in the real world.
Yes, county gig. I agree that there are some perks to SMI case loads. A good bunch of mine are conserved so they show up (which I guess is good if I don't want them to decomp). Actually some show up for their IM but not their MD/DO follow ups for like almost a year. Management wise, I'm just so far removed from SMI in the outpatient county setting.... The perks of which are they don't bust our backs for RVUS, they don't schedule 22 pts in hopes that 7 show up and sometimes 22 do, they do allow 60 minutes for the first visit with new pts....However, I also have to agree that there is a culture of, "Let's see how much we can push our luck. The new guy won't say anything due to being new." Boundaries. Yes, gigs can be like personality disorders.

Interesting about the point made regarding being judged based on the standard of care within the setting one practices. I thought it was one standard for all. We do get the occasional private practice caliber pt that wants to save money and has private practice expectations.

The best new job advice I got early on in my career was from a friend who started med school late and was in his fifties by the time he was a practicing physiatrist. His first outpatient job tried to get him to travel to multiple sites after signing on. He would simply reply with one-liner Emails to the director, "Sorry, that won't work."
And bam...More often than not they need us more than we need them, especially in psychiatry, especially in the indigent realm.

 

[annoyedpsychiatrist]

The point about hazing is of course pervasive in both medical training culture and its aftermath in the real world.
Yes, county gig. I agree that there are some perks to SMI case loads. A good bunch of mine are conserved so they show up (which I guess is good if I don't want them to decomp). Actually some show up for their IM but not their MD/DO follow ups for like almost a year. Management wise, I'm just so far removed from SMI in the outpatient county setting.... The perks of which are they don't bust our backs for RVUS, they don't schedule 22 pts in hopes that 7 show up and sometimes 22 do, they do allow 60 minutes for the first visit with new pts....However, I also have to agree that there is a culture of, "Let's see how much we can push our luck. The new guy won't say anything due to being new." Boundaries. Yes, gigs can be like personality disorders.

Interesting about the point made regarding being judged based on the standard of care within the setting one practices. I thought it was one standard for all. We do get the occasional private practice caliber pt that wants to save money and has private practice expectations.

The best new job advice I got early on in my career was from a friend who started med school late and was in his fifties by the time he was a practicing physiatrist. His first outpatient job tried to get him to travel to multiple sites after signing on. He would simply reply with one-liner Emails to the director, "Sorry, that won't work."
And bam...More often than not they need us more than we need them, especially in psychiatry, especially in the indigent realm.

" what a reasonably prudent similar healthcare provider would do under similar circumstances. " is ultimately what standard of care is. Essentially judged by another clinician with similiar training and how he would act in that setting/situation with that patient. Ultimately boils down to, did you do what most docs would have done in your situation? How can any doctor who suddenly inherits a patient on 3 antipsychotics, know the exact medication dose thats working/isnt working? Obviously if you took of all 3 at once that would be pretty dumb, but if you continued it because the patient has been hospitalzied 3434344 times and reportedly with these hes actually been stable, im going to be hard pressed to say theres a better solution, especially if hes not a candidate for clozapine. I think in the community setting its more vague than private practice, because honestly most docs probably wouldnt know what the hell to do in that situation. In private practice it may be more clear cut because youre getting less sick people, with a more clear treatment path to follow.

One of the unintentional perks of our field is its quite ambiguous sometimes.

i worked community health a year ago. i was seeing 20-23 patients a day and managed 5 midlevels. that was the job from hell. all for 300k. I make more than that now with no supervision and less patients per day.

 

[milesed]

Have you discussed this with the medical director?

 

[FlowRate]

Our clinic/organization policy is that it is not appropriate to transfer patients to other docs due to access concerns, which is the argument they made to transfer patients to you.

Access concerns should ultimately be handled by appropriate staffing and panel management (although good luck with this in a CMHC and also in many other employed settings.)

 

[clement]

Have you discussed this with the medical director?

I did discuss with a director (SW) who was largely absent during the meeting with a supervising MD. Hey, CMHC. I also Emailed these same folks with the CMO cc’d and got a reply with him, not cc’d.

After then quoting (verbatim) lines from the last visit on one case coming to me (directly preceding transfer) of a pt threatening to sue the transferring psychiatrist for declining to dole out benzos…They agreed I could make a list of inappropriate transfers and they would CONSIDER transferring some case back.

Anyway, no new outpatient shrink wants to be vulnerable to this kind of selection bias. If anything the supervisor should have redistributed cases if they truly wanted to even out loads.

The departed shrink whose cases I was supposed to get apparently had half the load go to a pharmacist. Curious that they didn’t just transfer those pts, ain’t it?

Still fuming… and summarized all of this in another Email using all but the word “ultimatum.”

It’s easy to make the psychiatrist on the receiving end of this feel as though it’s about cherry picking (gas lighting) or that, “We generally have a lot of sick cases in clinic.”

My reply to that one was, none but none of my new intakes over several months have been nearly as sick or complex as the…you guessed it…transfers from others. Perhaps these are pts from another era in clinic that have been passed around. None the less, malingering unveiled.

 

[clement]

Our clinic/organization policy is that it is not appropriate to transfer patients to other docs due to access concerns, which is the argument they made to transfer patients to you.

Access concerns should ultimately be handled by appropriate staffing and panel management (although good luck with this in a CMHC and also in many other employed settings.)

They used to have a supervisor even out case loads via redistribution…back in the day. Still better than other psychiatrists having at it….shipping out problem pts to the newcomer (a free-for-all with no outlined criteria)…under the guise of improving access and evening out case loads. But haven’t we been shipping out patients era after era including across state lines on Greyhound?

Mind you, these are quite stable patients that are just management challenges +/- liability. Like 40 of Zyprexa or 800 of I love me some Seroquel every night…Have you seen how many suicide attempts I have LISTED in my records? With no labs in 4+ years, nor vitals since COVID hit?

Best part is having 12 more months of PSLF motivation to put up with this. In part, it was a bit tough to find hybrid model 501c qualifying gigs…

Guess they can’t ding me at 2 annual reviews for speaking up? Not sorry to admit that this is partly why I’ve been so far removed from outpatient psychiatry (as someone else’s employee especially). PP might truly be the only sanctus! Union gig though. Might be time to grieve…

 

[SeniorWrangler]

This isn't even hazing, just dumping on the new guy. Hazing at least implies that some day you will be on top and get to haze others. My guess, based on observation and personal experience, is that leadership doesn't give a damn about it and won't do anything to improve the situation or keep you from leaving.

 

[clement]

This isn't even hazing, just dumping on the new guy. Hazing at least implies that some day you will be on top and get to haze others. My guess, based on observation and personal experience, is that leadership doesn't give a damn about it and won't do anything to improve the situation or keep you from leaving.

They agreed to consider taking “some” pts back if I make a list. The right way to do this, if at all, was for a supervisor to distribute pts to the new guy and not their current psychiatrists. Problem is, the supervisor is also dumping some too, so there’s a bias toward doing things this way (letting each doctor select the dump cohort). One telltale sign was when the supervisor started saying, “I have a Clozaril pt I’m going to GIVE you” within a few days of starting. Cloz, stable, no biggie, but I was wondering why the need to give me anyone if was to inherit a departed psychiatrist’s load? The whole thing has just been Sketch City.

 

[annoyedpsychiatrist]

They agreed to consider taking “some” pts back if I make a list. The right way to do this, if at all, was for a supervisor to distribute pts to the new guy and not their current psychiatrists. Problem is, the supervisor is also dumping some too, so there’s a bias toward doing things this way (letting each doctor select the dump cohort). One telltale sign was when the supervisor started saying, “I have a Clozaril pt I’m going to GIVE you” within a few days of starting. Cloz, stable, no biggie, but I was wondering why the need to give me anyone if was to inherit a departed psychiatrist’s load? The whole thing has just been Sketch City.

The right thing to do is to discuss the case with the other provider, and see if that provider would like to take the case. It is weird for other providers to send patients your way that they have been seeing. Usually when a provider does that, its not because they're a great/stable patient. Even if they're stable on clozapine, can still be a pain doing the reporting (esp if its weekly) and ensuring they're getting their labs

 

[clement]

The right thing to do is to discuss the case with the other provider, and see if that provider would like to take the case. It is weird for other providers to send patients your way that they have been seeing. Usually when a provider does that, its not because they're a great/stable patient. Even if they're stable on clozapine, can still be a pain doing the reporting (esp if its weekly) and ensuring they're getting their labs

I routinely consult on cases and/or attempt to get them back to their prior doctor in clinic. I’m being met with pushback in terms of leadership being able to decide who to return to their previous doctor. The clinic is transferring cases to me under the guise of other established doctors having excessively large loads and me needing to build my case load still. So they claim tougher cases aren’t being seen enough by their doctors and guess who gets those pts? Honestly, as stated by another poster, I should threatened to walk unless I can pick who goes back. However, they defend against this by making it seem I’m picking and choosing who I see.

 

[FlowRate]

What an incredibly toxic way for them to start off "collegial" relationships... Aside from finances, is there any reason you can't leave now? Geographically locked? Only CMHC in town and die hard CMH lover?

 

[Coupd'Cat]

I joined an outpatient clinic which despite being a setting with many indigent/uninsured patients, has extremely limited access to case management and even nursing for that matter.

I also live in a vary populous state where revolving door psychiatric care is more common due funding issues. Take your guesses.

Getting people linked with ACT takes upwards of six months etc. So when I joined, the plan was for me to take on the "neutral" (mixed bag) caseload of someone who'd left. Instead, I have inherited that caseload plus those who still practice w/ me were allowed to transfer 30-50 of their cases to my load. You guessed it.

They're shipping over their sickest SMI cases that require polypharmacy to maintain stabilty (i.e. 3+ antipsychotics, 2+ mood stabilizer, no labs in nearly a decade)... and some of their sickest borderlines (which I prefer to former). This SMI population isn't a hugely prevalent in our practice, but it's who they're transferring over.

Aside from not having managed this population in the outpatient setting with bare bones nursing in nearly a decade, no one wants to be the new psychiatrist getting the toughest of everyone else's case load. When I brought it up to leadership, I was told, "We have some tough cases. Sometimes they get symptomatic. Sometimes they get hospitalized."

I thought the goal of tx in the outpatient setting was to prevent hospitalization and not play musical chairs with liability. Shifting pts from caseload to caseload when opportune isn't helping such patients (seriously, some havent had a BMI recorded in nearly a decade). The excuse is that, "they need to be seen sooner and you have time since your load is still small."

How have others joining a clinic as the newest member handled this? Some of these pts are the damned if you do, damned if you don't variety...Liability if you keep prescribing, and liability based on a hx of violence and SA's if you don't.

The advice that I've gotten from my colleagues at the CMHC I'm at is to make it clear you can leave at any time.
Even if you would like to stay, it is good to remind the management that they would not like to go through the process of rehiring.
That's pretty much our only leverage. They don't actually care about doing things logically. Remind them that you can shift to private practice or find another job. In theory they care about retention, but they need a jab in the head to remember that people can and will leave.

I haven't faced the mass dumping that it sounds like you are experiencing, but I hope the same principles of being a highly credentialed worker with choices apply here.

 

[Coupd'Cat]

Also this sounds like a burning dumpster of a clinic. On the one hand, your patients are probably lucky to have someone new coming in and looking at their treatment with fresh, horrified eyes. On the other hand, do you want to go down with this mismanaged dangerbus? If they are happy dumping liability on you now, I'd bet they won't hesitate to throw you under the bus if and when something goes wrong.

 

[clement]

The advice that I've gotten from my colleagues at the CMHC I'm at is to make it clear you can leave at any time.
Even if you would like to stay, it is good to remind the management that they would not like to go through the process of rehiring.
That's pretty much our only leverage. They don't actually care about doing things logically. Remind them that you can shift to private practice or find another job. In theory they care about retention, but they need a jab in the head to remember that people can and will leave.

I haven't faced the mass dumping that it sounds like you are experiencing, but I hope the same principles of being a highly credentialed worker with choices apply here.

30% vacancy rate at this ginormous county “enterprise.”

 

[clement]

Also this sounds like a burning dumpster of a clinic. On the one hand, your patients are probably lucky to have someone new coming in and looking at their treatment with fresh, horrified eyes. On the other hand, do you want to go down with this mismanaged dangerbus? If they are happy dumping liability on you now, I'd bet they won't hesitate to throw you under the bus if and when something goes wrong.

Good point. There’s a bit of irony that comes with the position. We can leave in a heartbeat, but we can’t easily get fired (union). Mismanaged patients get passed down generation after generation, and yet most are delighted to simply access care.

It is a flaming liability dumpster for sure, and yet for an outpatient gig it’s magnificently chill in terms of daily volume and visit durations… w/ a hybrid setup (that is, if you don’t count phone visits from both home and the clinic as added liability).

The bottom line question being, does transient liability justify rolling with the punches for 12 more months in such settings until loans are forgiven? I should add, they have a sweet loan payment program once nicely hazed in (after a year). Decent pension too…I do feel bound by some of these perks.

Perhaps the best compromise is to not leave asap, but not make it a long term job. People do stick it out for a decade+ at said gig, which has made me question some of my disenchantment.

 

[Coupd'Cat]

Good point. There’s a bit of irony that comes with the position. We can leave in a heartbeat, but we can’t easily get fired (union). Mismanaged patients get passed down generation after generation, and yet most are delighted to simply access care.

It is a flaming liability dumpster for sure, and yet for an outpatient gig it’s magnificently chill in terms of daily volume and visit durations… w/ a hybrid setup (that is, if you don’t count phone visits from both home and the clinic as added liability).

The bottom line question being, does transient liability justify rolling with the punches for 12 more months in such settings until loans are forgiven? I should add, they have a sweet loan payment program once nicely hazed in (after a year). Decent pension too…I do feel bound by some of these perks.

Perhaps the best compromise is to not leave asap, but not make it a long term job. People do stick it out for a decade+ at said gig, which has made me question some of my disenchantment.

Do you have anything that you're doing on the side? Most of the people who stick around at our place are people who work at least a half day a week in private practice.

Having federal and state holidays help. I've found that taking liberal vacation helps as well. I tell myself it's in my patient's best interest if I'm gone intermittently, as opposed to leaving and forcing them to transition to another (likely temporary) therapist/psychiatrist once again.

I reserve my diminishing bucket of cares for my patients and the direct staff I interact with. I take very long walks. After I accepted that mismanagement and bad behavior seems to flourish like weeds in our steaming cesspool, I saw why the phrase "it's not my problem" exists. I used to think it was an excuse for inaction, but it's actually a survival mantra.

It's all a shame. I can't figure out how a place like this and the one you're describing can attract long-term well-trained psychiatrists. There's no pride in working under managers you can't respect and watching good people leave every month. It's substandard care for poor people but somehow that's okay because the general thinking is that poor people should be grateful to be "served." The mission statements at places like this disgust me.

If I were you I'd try to make it to a year. That's a relatively short time to become vested in a pension plan, if I read you correctly. And push back on nonsense in the meantime. But this is all balanced against how badly they shafted you with your case load. Document the hell out of everything. If your managers give you any verbal instructions do not follow them if you have an uneasy gut feeling, get that s* down in writing or in an email.

 

[clement]

Do you have anything that you're doing on the side? Most of the people who stick around at our place are people who work at least a half day a week in private practice.

Having federal and state holidays help. I've found that taking liberal vacation helps as well. I tell myself it's in my patient's best interest if I'm gone intermittently, as opposed to leaving and forcing them to transition to another (likely temporary) therapist/psychiatrist once again.

I reserve my diminishing bucket of cares for my patients and the direct staff I interact with. I take very long walks. After I accepted that mismanagement and bad behavior seems to flourish like weeds in our steaming cesspool, I saw why the phrase "it's not my problem" exists. I used to think it was an excuse for inaction, but it's actually a survival mantra.

It's all a shame. I can't figure out how a place like this and the one you're describing can attract long-term well-trained psychiatrists. There's no pride in working under managers you can't respect and watching good people leave every month. It's substandard care for poor people but somehow that's okay because the general thinking is that poor people should be grateful to be "served." The mission statements at places like this disgust me.

If I were you I'd try to make it to a year. That's a relatively short time to become vested in a pension plan, if I read you correctly. And push back on nonsense in the meantime. But this is all balanced against how badly they shafted you with your case load. Document the hell out of everything. If your managers give you any verbal instructions do not follow them if you have an uneasy gut feeling, get that s* down in writing or in an email.

Coup’d,
You’re in the know about this kind of setting. Your insight here is pure gold.

Yes, it’s all about survival mantras in some county settings. See some stable mega mismanaged cases at 3-4 month intervals 3-4x/year, and, if a golden opportunity arises, dump hard.

There are moments where I tell myself, I’m out ASAP, but then there are times when 4 out of 7 cases scheduled (total) don’t even show up and it all feels so humane (even luxurious).

Yes, at least one holiday most months and one weekday off. All very amenable to stacking a few vacation days monthly. No vacation the 1st year, but education days at home.

Pushing back on dumps, interval threats to leave, and vigorous documentation that I received said dumps of people w/o labs for years on moderate doses of Depakote, Li + 3 antipsychotics… +/- elderly personality disordered pts on buckets of benzos and Seroquel 800 for sleep who threaten SI at the prospect of any change.

Building my practice on the side is a perk of going along for the ride, even transiently for the year. I have yet to do so. People do come, keep this as a base salary, build a practice, leave. Some also stay decades and are vested in the pension (only up to part of salary) after 5 years. It’s also nice to be a union employee when thinking back on some past RVU based salary cut threats in academia or elsewhere.

On occasion I find myself struggling with the temptation to check out like every other psychiatrist there, going with the flow, not stirring this steamy cesspool/pot too much or all, but I can’t shed the feeling that I’ve been on the receiving end of substantial parasitism so far.

 

[Coupd'Cat]

Pushing back on dumps, interval threats to leave, and vigorous documentation that I received said dumps of people w/o labs for years on moderate doses of Depakote, Li + 3 antipsychotics… +/- elderly personality disordered pts on buckets of benzos and Seroquel 800 for sleep who threaten SI at the prospect of any change.

There is a special kind of rage that rises from looking out on a sea of stupid, harmful prescribing that's been going on for years. Why does this cause anger? Is it because we feel stuck and complicit even as we are trying to amend these regimens? Is it secondhand grief for how people have been prescribed often ineffective and harmful polypharmicopias just because it was easier for the psychiatrist to do so? This is a particular strain of rage.

What are your legal protections at your clinic? For us, suits are against the entity, not individual practitioners, and the system contracts with a gaggle of malpractice lawyers

It’s also nice to be a union employee when thinking back on some past RVU based salary cut threats in academia or elsewhere.

It sure is. Be careful though, sometimes a union has their own agenda. Issues tend to matter more to them if it's representative of a systemic problem, which makes sense as their leverage for change is the more people affected the more power
It would be also interesting to watch how the turnover is at your union. Our union organizers tend to burn out which doesn't help with building trust between them and union members, the latter of whom already have had a mega dose of learned helplessness

On occasion I find myself struggling with the temptation to check out like every other psychiatrist there, going with the flow, not stirring this steamy cesspool/pot too much or all, but I can’t shed the feeling that I’ve been on the receiving end of substantial parasitism so far.

These are fascinating organizations. The result of stirring is often that you attract attention to you usually from management, which violates a rule of survival. Voicing any desire for change is usually met with the response that it was tried before but someone (usually blaming staff) disagreed with it, or they might humor you for a while but give you absolutely no tools or resources. You have definitely been on the receiving end of substantial parasitism. They are hoping that the nice benefits (5 years into a vested pension is very good from where I'm looking, ours is pushing 20 years), relaxed scheduling, and maybe a drop of some social duty are enough sustenance to keep leeching what they need from you which is a body with a prescription pad.

Other reasons to stay - if you enjoy working with the direct staff, have some intellectual curiosity that hasn't been beaten out yet, knowledge that even doing the bare minimum of competent psychiatric care is better than what came before for your patients, and flexibility to do what you want with your practice as long as the overall structure doesn't care (and they usually don't as long as you meet some productivity standard that they get paid for and make them look good to outside accreditors). Personally, I want to see patients who are minoritized and/or poor which in this country which ends up meaning a publicly funded clinic or a FQHC where I would be a pill mill, and I'd rather work in the former for now because time is luxury both for me and for the person I can share an extra 30 minutes with if I want to. The people who are dealing with SMI and substance use and trauma and poverty need a whole team, so even if I took Medicaid in private practice I would only be seeing a sliver of fairly stable people which sounds boring now but might be more attractive after a few years.

 

[Coupd'Cat]

check out like every other psychiatrist there,

This also bothers me so much out at the same time as I understand it to such a minimal degree. It's like watching animals in cages then realizing you are one of them too. Some of them continue raging, some of them give up, and some of them grovel whenever the owner comes by.

 

[forchinet121]

Good point. There’s a bit of irony that comes with the position. We can leave in a heartbeat, but we can’t easily get fired (union). Mismanaged patients get passed down generation after generation, and yet most are delighted to simply access care.

It is a flaming liability dumpster for sure, and yet for an outpatient gig it’s magnificently chill in terms of daily volume and visit durations… w/ a hybrid setup (that is, if you don’t count phone visits from both home and the clinic as added liability).

The bottom line question being, does transient liability justify rolling with the punches for 12 more months in such settings until loans are forgiven? I should add, they have a sweet loan payment program once nicely hazed in (after a year). Decent pension too…I do feel bound by some of these perks.

Perhaps the best compromise is to not leave asap, but not make it a long term job. People do stick it out for a decade+ at said gig, which has made me question some of my disenchantment.

You’re too afraid of liability, psychiatrists are the least sued..a lot of what you’re describing sounds kind of standard in that I’ve seen it numerous times (phone visits, not getting labs or vitals, etc) so I wouldn’t stress out about it too much

 

[clement]

There is a special kind of rage that rises from looking out on a sea of stupid, harmful prescribing that's been going on for years. Why does this cause anger? Is it because we feel stuck and complicit even as we are trying to amend these regimens? Is it secondhand grief for how people have been prescribed often ineffective and harmful polypharmicopias just because it was easier for the psychiatrist to do so? This is a particular strain of rage.

What are your legal protections at your clinic? For us, suits are against the entity, not individual practitioners, and the system contracts with a gaggle of malpractice lawyers



It sure is. Be careful though, sometimes a union has their own agenda. Issues tend to matter more to them if it's representative of a systemic problem, which makes sense as their leverage for change is the more people affected the more power
It would be also interesting to watch how the turnover is at your union. Our union organizers tend to burn out which doesn't help with building trust between them and union members, the latter of whom already have had a mega dose of learned helplessness



These are fascinating organizations. The result of stirring is often that you attract attention to you usually from management, which violates a rule of survival. Voicing any desire for change is usually met with the response that it was tried before but someone (usually blaming staff) disagreed with it, or they might humor you for a while but give you absolutely no tools or resources. You have definitely been on the receiving end of substantial parasitism. They are hoping that the nice benefits (5 years into a vested pension is very good from where I'm looking, ours is pushing 20 years), relaxed scheduling, and maybe a drop of some social duty are enough sustenance to keep leeching what they need from you which is a body with a prescription pad.

Other reasons to stay - if you enjoy working with the direct staff, have some intellectual curiosity that hasn't been beaten out yet, knowledge that even doing the bare minimum of competent psychiatric care is better than what came before for your patients, and flexibility to do what you want with your practice as long as the overall structure doesn't care (and they usually don't as long as you meet some productivity standard that they get paid for and make them look good to outside accreditors). Personally, I want to see patients who are minoritized and/or poor which in this country which ends up meaning a publicly funded clinic or a FQHC where I would be a pill mill, and I'd rather work in the former for now because time is luxury both for me and for the person I can share an extra 30 minutes with if I want to. The people who are dealing with SMI and substance use and trauma and poverty need a whole team, so even if I took Medicaid in private practice I would only be seeing a sliver of fairly stable people which sounds boring now but might be more attractive after a few years.

“The people who are dealing with SMI and substance use and trauma and poverty need a whole team…”

💯

 

[clement]

You’re too afraid of liability, psychiatrists are the least sued..a lot of what you’re describing sounds kind of standard in that I’ve seen it numerous times (phone visits, not getting labs or vitals, etc) so I wouldn’t stress out about it too much

…Standard until individually on the receiving end of sue. In the geographic areas I’ve practiced, malpractice rates for psychiatrists are among the highest in the nation- I presume COL related but also incidence of sue me because you didn’t get labs since 2016 and are on loads of lithium and depakote plus methodone from your mill, two typicals, plus Geodon, and so on.

 

[clement]

There is a special kind of rage that rises from looking out on a sea of stupid, harmful prescribing that's been going on for years. Why does this cause anger? Is it because we feel stuck and complicit even as we are trying to amend these regimens? Is it secondhand grief for how people have been prescribed often ineffective and harmful polypharmicopias just because it was easier for the psychiatrist to do so? This is a particular strain of rage.

What are your legal protections at your clinic? For us, suits are against the entity, not individual practitioners, and the system contracts with a gaggle of malpractice lawyers



It sure is. Be careful though, sometimes a union has their own agenda. Issues tend to matter more to them if it's representative of a systemic problem, which makes sense as their leverage for change is the more people affected the more power
It would be also interesting to watch how the turnover is at your union. Our union organizers tend to burn out which doesn't help with building trust between them and union members, the latter of whom already have had a mega dose of learned helplessness



These are fascinating organizations. The result of stirring is often that you attract attention to you usually from management, which violates a rule of survival. Voicing any desire for change is usually met with the response that it was tried before but someone (usually blaming staff) disagreed with it, or they might humor you for a while but give you absolutely no tools or resources. You have definitely been on the receiving end of substantial parasitism. They are hoping that the nice benefits (5 years into a vested pension is very good from where I'm looking, ours is pushing 20 years), relaxed scheduling, and maybe a drop of some social duty are enough sustenance to keep leeching what they need from you which is a body with a prescription pad.

Other reasons to stay - if you enjoy working with the direct staff, have some intellectual curiosity that hasn't been beaten out yet, knowledge that even doing the bare minimum of competent psychiatric care is better than what came before for your patients, and flexibility to do what you want with your practice as long as the overall structure doesn't care (and they usually don't as long as you meet some productivity standard that they get paid for and make them look good to outside accreditors). Personally, I want to see patients who are minoritized and/or poor which in this country which ends up meaning a publicly funded clinic or a FQHC where I would be a pill mill, and I'd rather work in the former for now because time is luxury both for me and for the person I can share an extra 30 minutes with if I want to. The people who are dealing with SMI and substance use and trauma and poverty need a whole team, so even if I took Medicaid in private practice I would only be seeing a sliver of fairly stable people which sounds boring now but might be more attractive after a few years.

Unfortunately not like the VA where individuals don’t get sued. I am that’s the primary setting we come across such a scenario.

 

[milesed]

If this is how you're being treated, I'd be looking for another job as it's likely a good indication for how other things will be handled going forward.

 

[clement]

If this is how you're being treated, I'd be looking for another job as it's likely a good indication for how other things will be handled going forward.

One thousand percent. Looking vigorously. Immediate geography being a limiting factor, slightly. Like if one of these burning dumpster cases they’re dumping on me hits the fan, these people sure as hell won’t back me up.

Update: I had a meeting with some management folks about the dumping and their response was that perhaps I’m doubting the “integrity” of my colleagues… and was hoping to inherit more “straight forward” cases from psychiatrists actively dumping cases on me.

They reiterated allegedly all cases are complex in their health system. This is contradicted by the fact that they admit “easier” cases went to a new NP. Mmkay.

Best yet, they threatened my hybrid work model saying maybe I’m worried about the dumping transfer process because I work from home 3 days a week and not 2 🤣…and that I need to come in to the office at least 2 days like my colleagues (AKA retaliatory/punitive response).

Mind you, they hired me during COVID saying I could work from home with a newborn in tow, but it took so long to on board that they almost immediately turned it into working on site 50% by the time I started (yes, I know many work places are going through this). However, it’s clear the same dumpers resent me for working from home more days than they do. The toxicity is giving me Pepcid cravings. Place blows. I’m too old for this mickey-mousery, but experienced bait ‘n switch once before when I first graduated.

 

[clausewitz2]

One thousand percent. Looking vigorously. Immediate geography being a limiting factor, slightly. Like if one of these burning dumpster cases they’re dumping on me hits the fan, these people sure as hell won’t back me up.

Update: I had a meeting with some management folks about the dumping and their response was that perhaps I’m doubting the “integrity” of my colleagues… and was hoping to inherit more “straight forward” cases from psychiatrists actively dumping cases on me.

They reiterated allegedly all cases are complex in their health system. This is contradicted by the fact that they admit “easier” cases went to a new NP. Mmkay.

Best yet, they threatened my hybrid work model saying maybe I’m worried about the dumping transfer process because I work from home 3 days a week and not 2 🤣…and that I need to come in to the office at least 2 days like my colleagues (AKA retaliatory/punitive response).

Mind you, they hired me during COVID saying I could work from home with a newborn in tow, but it took so long to on board that they almost immediately turned it into working on site 50% by the time I started (yes, I know many work places are going through this). However, it’s clear the same dumpers resent me for working from home more days than they do. The toxicity is giving me Pepcid cravings. Place blows. I’m too old for this mickey-mousery, but experienced bait ‘n switch once before when I first graduated.

They clearly don't let talent go lightly, but hurl it away from them with great force.

 

[clement]

They clearly don't let talent go lightly, but hurl it away from them with great force.

I’d like to. Believe me. I think I’m also doing the job of at least 2.5 nurses to boot.

 

[clement]

So the story of how this burning dumpster went down charred is as follows:
They told me they’d take back some of the pts other psychiatrists wanted to shed off their load but kept dumping. I complained to the cmo who did nothing in true cmo style. They retaliated by taking away telework, increasing work load, decreasing breaks and admin time, hyperscrutinizing/hypermicromanaging. SW director had past retaliation claims against him apparently…This is a county department that operates via social work administrators. It’s not a true medical model let’s say. So I quit and 2 others out of 6 psychiatrists quit.
Whoever above said dumping pts on the new guy speaks volumes about admin, was right.

PS unions are useless unless you’re being disciplined or it’s any issue impacting the masses. The poster above was also right on that front. You can be discriminated and retaliated against, no probs. If you complain about management in the public sector, it’ll just sit in a pile for a year.

PS2 they refused to pay vacation payout due to being employed just under a year. All legal though in my state the private sector must pay vacation. Courts lookout for the sovereignty of public entities so they can do as they wish if it’s not in your union contract.

PS3 most employee sided lawyers don’t want to deal with public entity employers.

Think 2x about that golden pension or loan perks when you apply for such public sector gigs. It’ll take 2-4 months to get credentialed elsewhere. 11 more months of PSLF left.

Loans are now in repayment plus cobra is $. Timing is awesome.
Total damages 88K.

On a more primitive level of vetting potential employers, I’ve learned that the very early interactions/reactions when asking questions about the job (especially roles/responsibilities) are very foretelling… even if just a subtlety in the tone of voice.

As someone who is not a recent grad and now gracefully grills potential employers on their recruitment frills, I find many do get annoyed or discouraged about one’s candidacy…and a few good ones don’t.

 

[Candidate2017]

So the story of how this burning dumpster went down charred is as follows:

Maybe you'll get lucky and get a great gig where you are respected, bureaucracy and stress are low, pay is high, and you'll actually help grateful patients. And you can come back and post about it, and I will like your post.

But medicine, especially psychiatry, is generally a dumpster fire. So, always bring plenty of marsh mellows, chocolate, and graham crackers to make s'mores.

 

[clement]

Maybe you'll get lucky and get a great gig where you are respected, bureaucracy and stress are low, pay is high, and you'll actually help grateful patients. And you can come back and post about it, and I will like your post.

But medicine, especially psychiatry, is generally a dumpster fire. So, always bring plenty of marsh mellows, chocolate, and graham crackers to make s'mores.

You are correct.

Plenty of such places exist in less psychiatrist dense and lower cost of living cities.

 

[comp1]

I've found there are often reasons very few psychiatrists live in a given area...

 

[Merovinge]

I've found there are often reasons very few psychiatrists live in a given area...

Of course, but one man's trash is another's treasure. I live in an area I absolutely love but many people would find it uninhabitable or have significant concerns around it. And while the population is clearly showing that urban>>rural in terms of preference, there are still plenty of people who prefer rural living.

 

[Therapist4Chnge]

Why subject yourself to that? I’d be aggressively exploring options to leave while also documenting in writing the dumped cases and leadership’s responses. Clearly you got got, and they will ride you as long as you allow them to do it.