Transitioning to outpatient year

[lyla]

PGY2 here.

We started our outpatient rotations this past week. I am at a private pay clinic half the week, and a safety-net/community clinic the other half of the week. I'm normally very efficient with my work, but I've found outpatient psychiatry so far to be more stressful/demanding emotionally than inpatient or hospital work. Specifically, I'm having a difficult time keeping visits contained within our time frame (15 minute med check turns into 30 minutes or more, I find it difficult to interrupt people I've just met). A decent number of my patients also want psychotherapy with their med management and I am concerned that due to being significantly younger than many of my patients, they will not perceive my psychotherapy as valid/helpful (as opposed to getting it from someone closer in age to them).

Any tips for the transition from hospital psychiatry to outpatient psychiatry? Thanks!

EDIT: I meant 30 minute med checks, not 15 minute med checks! lol

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[wolfvgang22]

15 minute med checks, huh?
Here is what you do.
Tell patients the first time you see them that you are unfortunately unable to provide psychotherapy, you are the medication guy. Nip it in the bud, do not let them ramble. Be pleasant, but take the lead in the appointment immediately upon entering the office. Ask "so how are you doing with these medications?". Ask if they are having side effects. Have the patient rate her mood on a scale of 1 to 10. Use tools like brief depression inventories to keep the patient on task. If they start rambling about something else, offer to refer them to the person who does therapy (usually a social worker).

Practice tactful verbal redirection, this will take time to learn which is why you are there. Steal every useful phrase or action you see your attendings use. It is pointless to have any fear while you learn what works with your practice style. Age matters not.

Use body language to signal when it is time to end the appointment. Lean forward, and consciously act as though you are about to stand and head for the door. You will find most patients will start to get up, too. Then escort the patient out to the scheduler while you tell the patient how nice it was to see them today. Always be aware of your body language, tone of voice, and word choice or intentional silence. Every word and action you do in clinic should be aimed at your goal of efficiently assisting the patient in a pleasant, therapeutic manner.

These are just a few quick tips. As you learn therapy skills, such as reflective listening and clarification, among many others, use them to assist the patient through the medication management appointment quickly.

 

[splik]

PGY2 here.

We started our outpatient rotations this past week. I am at a private pay clinic half the week, and a safety-net/community clinic the other half of the week. I'm normally very efficient with my work, but I've found outpatient psychiatry so far to be more stressful/demanding emotionally than inpatient or hospital work. Specifically, I'm having a difficult time keeping visits contained within our time frame (15 minute med check turns into 30 minutes or more, I find it difficult to interrupt people I've just met). A decent number of my patients also want psychotherapy with their med management and I am concerned that due to being significantly younger than many of my patients, they will not perceive my psychotherapy as valid/helpful (as opposed to getting it from someone closer in age to them).

Any tips for the transition from hospital psychiatry to outpatient psychiatry? Thanks!

I am not sure how these clinics are set up but the transition to outpatient is a huge learning curve and one of the points in your residency when you will learn the most. If they are wanting you to be their therapist that is a good thing, and they will be very glad to see you! It is natural to feel like you don't have much to offer because you are a rookie and truth be told, probably not very good. Regardless, I focused on geriatrics during my residency so many of my therapy patients were much older. If anything, I found that they were much more receptive and deferential to my "expertise" than younger patients. remember you are a doctor so patients will put a lot of faith in you. these feelings of inadequacy are fine. I sucked as a PGY-2, you will marvel back as you progress through the years and learn how to become an effective, empathic psychiatrist. Just be you.

if you are able to see psychotherapy patients in these clinics, my advise would be to take on as many as you can. Then you won't have to worry about stacking up all the "med management" patients! I do find it troubling if you are expected to see outpatients you've not met before in 15 minute visits as a PGY-2. This is supposed to be a learning experience for you. Take control of the schedule as far as you can, ask all patients new to you to be allotted 30mins or even an hour. When you schedule patients for follow up request the time you need. At this stage of your training, you should not be focusing on being efficient, but on being skilled in diagnosis, psychopharmacology, risk assessment, formulation, utilizing community resources, interviewing, and supportive psychotherapy. You cannot effective to appropriately efficient, until you have first learned how to be effective.

In terms of your feelings of not having much to offer. This is a normal feeling for beginning residents. You should be discussing these feelings, and how to best utilize them, during supervision. I would recommend Michels and Mackinnon's The Psychiatric Interview in Clinical Practice and The Art of Psychotherapy both of which are written for residents beginning outpatient psychotherapy.

The other tip I have is you cannot help patients you don't like (this is especially true for psychotherapy). There is nothing wrong with hating your patients. But if it's not going to go away (because some patients are just horrible) life is too short to put up with that BS - terminate them! It is the best thing for both of you. Also remember - patients will vote with their feet. If they don't like you, they won't come back. That's okay, goodness of fit is important of psychiatry and you and your patients will be much more satisfied if there is at least something of a "fit".

Also it sounds like you have difficulty interrupting patients. Again this is great fodder for your supervision or personal psychotherapy. But set a challenge to yourself to interrupt patients. You can count to 10 and then interrupt. I usually warn people "because we have so little time to get through a lot I am going interrupt you and redirect you, but please don't take offense." and I see people for 3 hours at a stretch btw, not 15mins! Patients who get upset about it - it is usually diagnostic and again great opportunity to explore the transference.

 

[hamstergang]

I still struggle with this still and I finished my C&A fellowship 7 months ago. I think a large part of the solution is:

If they start rambling about something else, offer to refer them to the person who does therapy (usually a social worker).

However, the challenge is how do you actually say this? You don't want the patient to get the feeling that you don't care about their problems, but you need them to realize that venting about every detail that's occurred since the last visit isn't helpful to you in figuring out if their current medication regimen is appropriate and safe.

 

[Merovinge]

I still struggle with this still and I finished my C&A fellowship 7 months ago. I think a large part of the solution is:


However, the challenge is how do you actually say this? You don't want the patient to get the feeling that you don't care about their problems, but you need them to realize that venting about every detail that's occurred since the last visit isn't helpful to you in figuring out if their current medication regimen is appropriate and safe.

I usually say something along the lines of "Lets focus on what we have time to address and improve today, if you need more help than that lets find you resources to tackle those."(or schedule an earlier f/u depending on the problem/pt) I find people generally get the idea if you bring their attention to it that there is only so much you can do in 1 doctor's apt and that is often changing a med and getting a referral.

 

[MacDonaldTriad]

Approach A:

“Mr. X, I understand that to do this in the best possible way, we should spend most of this morning trying to cover your lifetime of events and communicate all of the details that would let me understand all of you formative experiences that has brought you to where you are now. Unfortunately, I am going to say this same thing to seven other people this morning. Fortunately, there is nothing that says we have to do this all in the first visit and I’m not going anywhere. We will cover as much as we can today, but I promise, we will continue to work together over time.”

Approach B:

“I’m sorry, but I think you have mistaken me for someone who cares.”

Most patients will assume the default approach B unless you clarify something close to A so you are going to have to get used to paraphrasing the above.

As far as your youth and the appearance of a lack of life experience, youth is an appearance and not always a measure of substance.

“Mr. X, I’m glad you pointed out my age if it has been an issue that is bothering you. The fact that I am younger than you is undeniable. Are you of the opinion that no one my age can be able to help you, or is it still a matter of skepticism and you don’t have any specific examples where my age has been an issue in our therapeutic process? If it has, we should talk about it and I am all ears. If this has been happening or if it does happen, it likely will be good grist for our therapeutic mill and please tell.”

These straw men that can seem like elephants in the room blow away fairly easily when confronted head on. Although I kind of miss being called too young, this will evolve to other equally invalid forms of resistance. You will always be too dark or too light, too blond, or too brunette, too male or too female, too Catholic or too Jewish. Most likely your age is more your issue than theirs.

“Maybe you are right, I’m just a complete idiot, so where does that leave us? You were telling me about what happened last weekend….”

 

[Nasrudin]

I think being pressured to see 15 min med checks is f'n ridiculous in all situations. But it's a crime for a newly arriving 3rd year.

Your program sucks. And is using you to dispense medications.

 

[Nasrudin]

Tell me if any of your supervisors cranked out 15 min med checks as residents.

Ask them.

 

[st2205]

Tell me if any of your supervisors cranked out 15 min med checks as residents.

Ask them.

I'm not sure what's worse: 15 minute med checks or a 30 minute appointment that you have to checkout to an attending who then sees the patient.

 

[Nasrudin]

I'm not sure what's worse: 15 minute med checks or a 30 minute appointment that you have to checkout to an attending who then sees the patient.

What?!

WTF is happening. This sounds like a residency twighlight zone.

We should be seeing all patients ourselves independently with supervision of specific types of therapy and general case load supervision that are consultants for questions and and review of cases and new admissions only. We should see only the very exceptional case that only requires 15-2o min which would be a very high functioning long stable person on a stimulant or something like that. And then only if they're not interested in talk therapy.

Otherwise therapy and medications management should be contiguous and interchangeable. Better...amalgamated. And take 30 minutes at the absolute minimum. And that's only utilizing the most liberal possible meaning of therapy, possibly limited to the meaning of medications, and then a cross examination of that process, the neurobiology of them, their proposed mechanisms and the mechanisms of their side effects, heath education, sex education, general social well-being and social functioning assessments and interventions, the interaction of the medications with those....****...even a proper placebo effect takes a little time to work up the mojo.

Doesn't....anybody...make love anymore...?!!? F.... it's all psych porn!??

 

[lyla]

Sorry! I meant 30 minute med checks. lol. But good advice all around, thanks everyone!

 

[Nasrudin]

Sorry! I meant 30 minute med checks. lol. But good advice all around, thanks everyone!

Sorry. I guess i have pre-loaded rants. Then splik, wolfgang, MacTriad have you covered.

I would just add that, efficiency should be a secondary goal. Strive for excellence and artistry. And remember that we're training in a system that is trying to make you into a rx-ing cog.

I'm training like I want to be. Like how I think the encounters should be. It's more exhilarating and exhausting. But 3rd year of psych residency has been the best year of employed service i've ever experienced.

I think part of why I reacted like that above. Is because I'm worried about the quality of this experience I'm having as a 3rd year being degraded.