VA Psychiatry Pros and Cons

[Achillees]

As the title suggests, I am interested in hearing about some lesser known advantages and disadvantages of becoming a career VA Psychiatrist.

To start off, some pros:
-Less concern about dealing with insurance companies
-Decent PTO package
-Collegiality (having access to fellow Psychiatrists and other clinicians and auxiliary staff)

Cons:
-Added dimension of complexity w/ pts when considering service connection, which obfuscates diagnostic clarity at times
-Possible limitations in diversity of pt populations (i.e. only seeing veterans)


Obviously not an exhaustive list, but I'm curious to learn of others I'm not aware of. I understand a lot of these points can be region-dependent, and there'll be strong opinions.

For clarity, I'm a PGY-4 resident considering a position at the VA.

Thank you

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[Fan_of_Meehl]

As the title suggests, I am interested in hearing about some lesser known advantages and disadvantages of becoming a career VA Psychiatrist.

To start off, some pros:
-Less concern about dealing with insurance companies
-Decent PTO package
-Collegiality (having access to fellow Psychiatrists and other clinicians and auxiliary staff)

Cons:
-Added dimension of complexity w/ pts when considering service connection, which obfuscates diagnostic clarity at times
-Possible limitations in diversity of pt populations (i.e. only seeing veterans)


Obviously not an exhaustive list, but I'm curious to learn of others I'm not aware of. I understand a lot of these points can be region-dependent, and there'll be strong opinions.

For clarity, I'm a PGY-4 resident considering a position at the VA.

Thank you

One thing to consider would be that, a few years back, the VA created (at least at my facility) two administrative positions to supervise the entire 'Mental Health Product Line' (including psychiatrists, psychologists, social workers, etc.) and I think the titles are something like Associate Chief of Staff for Mental Health and, directly under them, Deputy Chief of Staff for Mental Health. At my facility, both of these are social workers who--at least in my estimation--lack practical clinical experience and sophistication in comparison to the average practicing mental health clinician at the facility and are primarily politicians who oversee the top-down implementation of 'quality improvement' efforts from National-->VISN-->Local Facility. These 'quality improvement' efforts seem more like ways to manipulate numbers to make people 'look good' rather than actual quality improvement efforts.

The top M.D. (psychiatrist) at our local facility is 'under' these two social workers administratively. Of course, the psychiatrists are (technically) clinically supervised by an M.D., but what I have witnessed over the years is that political/administrative hierarchical position often trumps clinical acumen and credentials in this system. My facility may be an outlier, though. The fact that you may be effectively supervised by a mental health social worker (at least administratively) might be something to consider.

 

[TexasPhysician]

Pros: benefits, supporting an honorable population, pension
Cons: patient load, incentives for patients to not improve, support staff are often not very help (low risk of being fired), answer to many people that have less education than you.

 

[Achillees]

One thing to consider would be that, a few years back, the VA created (at least at my facility) two administrative positions to supervise the entire 'Mental Health Product Line' (including psychiatrists, psychologists, social workers, etc.) and I think the titles are something like Associate Chief of Staff for Mental Health and, directly under them, Deputy Chief of Staff for Mental Health. At my facility, both of these are social workers who--at least in my estimation--lack practical clinical experience and sophistication in comparison to the average practicing mental health clinician at the facility and are primarily politicians who oversee the top-down implementation of 'quality improvement' efforts from National-->VISN-->Local Facility. These 'quality improvement' efforts seem more like ways to manipulate numbers to make people 'look good' rather than actual quality improvement efforts.

The top M.D. (psychiatrist) at our local facility is 'under' these two social workers administratively. Of course, the psychiatrists are (technically) clinically supervised by an M.D., but what I have witnessed over the years is that political/administrative hierarchical position often trumps clinical acumen and credentials in this system. My facility may be an outlier, though. The fact that you may be effectively supervised by a mental health social worker (at least administratively) might be something to consider.

Thanks for your response.
That definitely IS something of concern. I think our regional Lead Psychiatrist is under a Psychologist. Now, how much better that is vs an MSW, I don't know. Asking a naive-sounding question now - how much do these administrative roles affect the Psychiatrist's daily work? I understand the ever-changing policies and additional documentation etc, but surely that much is to be expected in as vast an establishment as the VA.
My only reprieve to that point is, at least in my regional VA, it's fairly easy to jump ship. That's a privilege I fully intend to use if the environment becomes too untenable.
If it matters, I would be working primarily as an outpatient psychiatrist so metrics such as length of stay etc have less of an effect on my daily life.

 

[Achillees]

Pros: benefits, supporting an honorable population, pension
Cons: patient load, incentives for patients to not improve, support staff are often not very help (low risk of being fired), answer to many people that have less education than you.

Thanks for your response. I intend to work in the outpatient setting and, to my knowledge, the patient load is fairly average at 12-14 pts daily. Now, I am concerned regarding my ability to sustain years of M-F full-time outpatient work. The veteran population can be taxing, especially with regards to the lack of incentive to improve.

 

[Mass Effect]

but what I have witnessed over the years is that political/administrative hierarchical position often trumps clinical acumen and credentials in this system.

This. So much this.

Pros: benefits, supporting an honorable population, pension
Cons: patient load, incentives for patients to not improve, support staff are often not very help (low risk of being fired), answer to many people that have less education than you.

And also this.

 

[Fan_of_Meehl]

Thanks for your response.
That definitely IS something of concern. I think our regional Lead Psychiatrist is under a Psychologist. Now, how much better that is vs an MSW, I don't know. Asking a naive-sounding question now - how much do these administrative roles affect the Psychiatrist's daily work? I understand the ever-changing policies and additional documentation etc, but surely that much is to be expected in as vast an establishment as the VA.
My only reprieve to that point is, at least in my regional VA, it's fairly easy to jump ship. That's a privilege I fully intend to use if the environment becomes too untenable.
If it matters, I would be working primarily as an outpatient psychiatrist so metrics such as length of stay etc have less of an effect on my daily life.

Speaking of 'metrics'...hold onto your hat. In response to the question of how much 'effect' these non-psychiatrist administrative types will have on your daily work? (a) I think your psychiatrist colleagues in the VA could better address that than I can so I defer to them; (b) in general in mental health (outpatient) there has been a drive to push 'one-size-fits-all' top-down mandates to structure clinical care and to collect 'metrics' for 'compliance' around these directives with diminishing respect for individual clinician judgment and decision-making in context; (c) we are on the cusp of them mandating outcome 'metrics' on all outpatient cases and ultimately demanding that either you demonstrate effective response (read symptom reduction on self-report symptom checklists) over time or adjusting the treatment plan. Now, in principle, this is good practice but they won't be adjusting your caseload or schedule to accommodate the extra workload, I'm pretty sure of that. Conducting what is essentially a single-case-design treatment outcome study on every single case in your caseload (I have well over 100) is a noble idea but is sure to be extra work. Also, how likely do you think it is that service-connected (for mental health disability / PTSD) veteran patients are going to be to put their monthly disability payments (that supports their family, housing, food, etc.) in jeopardy by self-reporting dramatically reduced symptoms on these checklists? Sure, many will. But many won't. What will this look like for prescribing providers? It's anyone's guess. However, once we have a couple of years of VA 'metrics' on self-reported lack of symptom reduction, then we're gonna get the political push to dismantle the VA under the argument that it's not working (which, I dunno, maybe it isn't). I don't think it's unlikely that in the near future all outpatient treatment providers will have to regularly 'report' to clinical 'overseers' (who don't do therapy or prescribe meds themselves) who will 'hold accountable' the providers for 'outcomes' with their patients in regard to symptom self-report measures. I can't guarantee it...but I'd bet on it, given the current climate, governing philosophy, and trends.

 

[SourceOfDenial]

Like the saying goes..if you’ve seen one VA—you’ve seen one VA.

As much as it would be nice to generalize, the on the ground/local politics and workings of the facility is a lot more important than what someone says about a VA in a neighboring state, or across the country. One thing that I have noticed at several VA now it IS really hard to get good support staff.

 

[EarlyCareerAcademicPsych]

Like the saying goes..if you’ve seen one VA—you’ve seen one VA.

I think this is true. You'll get the most useful information from the specific medical center or CBOC (community-based outpatient clinic) where you are looking to work.

I work primarily in outpatient psychiatry at a Level 1 VA Medical Center across the street from a major medical center (the residency program across the street feeds most of the available positions at this VA and it is a high-caliber training program). I do 50% individual and psychotherapy. I have been at my VA for 11 years. I worked in an integrated primary care-mental health clinic and also I worked in the psych ER for some years. I do a lot of resident teaching and supervision. Here are my observations at this VA:
1) The mental health leadership is interprofessional and - fortunately - it is done by highly qualified staff. The ACOS for Mental Health is a psychiatrist. The Division Leadership is psychiatry, psychology and social work. I could see this not going well but that hasn't been the case where I work.

2) Support staff is variable. Right now, I work with EXCELLENT clerks who are not only competent and detail-oriented but who are pro-active. This is not the case throughout the medical center.

3) Service-connected disability stuff is really not a big deal in my experience. Nobody comes to the VA because they are happy in life. It is easy enough to make an assessment and then get done with people who have secondary gain. This doesn't really bother me much.

4) My colleagues are truly outstanding. This includes psychiatry, psychology and social work. I love working with the people in my medical center.

5) I very much enjoy working with patients who would likely not otherwise get such high-quality care (with regard to socioeconomic status). This makes the VA a good fit for me.

Good luck!

 

[hebel]

The biggest con for me with VA work is the relative lack of variety. Ancedotely, there seems to be a bimodal grouping of either personality disordered young men +/- a SUD and another grouping of Vietnam era guys who often seem to not know how to retire right (usually present as lonely, "not motivated," purposeless, often with real financial stressors). As an aside, in both of these groups a large large majority seem to have either a previous dx or service connection listed for PTSD.

There's obviously other kinds of patients and diagnoses to see, but I'm talking general trends I've observed personally.

 

[SourceOfDenial]

The biggest con for me with VA work is the relative lack of variety. Ancedotely, there seems to be a bimodal grouping of either personality disordered young men +/- a SUD and another grouping of Vietnam era guys who often just seem to not know how to retire right (usually present as lonely, "not motivated," purposeless, often with real financial stressors). As an aside, in both of these groups a large large majority seem to have either a previous dx or service connection listed for PTSD.

For your Vietnam era cohort—it’s worthwhile looking into the framework offered by Late Onset Stress Symptomatology or Later Adulthood Trauma Reengagement. May help to understand the process some of these folks are going through.

The above comment makes me realize how little residency prepares us for geropsych principles like gerotranscendence, navigating serious illness, late ericksonian stages etc

 

[hebel]

For your Vietnam era cohort—it’s worthwhile looking into the framework offered by Late Onset Stress Symptomatology or Later Adulthood Trauma Reengagement. May help to understand the process some of these folks are going through.

The above comment makes me realize how little residency prepares us for geropsych principles like gerotranscendence, navigating serious illness, late ericksonian stages etc

*sigh*, I expected a post with this sort of tone. From your reading of my post, what are you infering about my actual formulation and treatment of these patients?

 

[SeniorWrangler]

Mandates from the top which may not be questioned are a growing part of psychiatry elsewhere than the VA too. The place I used to work signed on with an ACO that mandated that every psych visit include a PHQ-9 and that we show a certain numeric improvement in order to qualify for bonuses.

 

[clausewitz2]

Mandates from the top which may not be questioned are a growing part of psychiatry elsewhere than the VA too. The place I used to work signed on with an ACO that mandated that every psych visit include a PHQ-9 and that we show a certain numeric improvement in order to qualify for bonuses.

That seems like a really excellent way to get a bunch of forged PHQ-9s/ sessions largely spent "helping" clients fill them out.

 

[WisNeuro]

Mandates from the top which may not be questioned are a growing part of psychiatry elsewhere than the VA too. The place I used to work signed on with an ACO that mandated that every psych visit include a PHQ-9 and that we show a certain numeric improvement in order to qualify for bonuses.

These BS initiatives are not unique to psychiatry. My spouse's bonuses are ties to how many of their patients stop smoking and maintain an A1c within a certain level.

 

[Sushirolls]

That seems like a really excellent way to get a bunch of forged PHQ-9s/ sessions largely spent "helping" clients fill them out.

This just means there will be selective pressure against accepting patients who are likely to not have that ideal downward trend...

 

[clausewitz2]

This just means there will be selective pressure against accepting patients who are likely to not have that ideal downward trend...

I can't imagine a place that requires you to complete these and pays based on the result gives you the least bit of say in who gets assigned to your caseload.

 

[Sushirolls]

These BS initiatives are not unique to psychiatry. My spouse's bonuses are ties to how many of their patients stop smoking and maintain an A1c within a certain level.

I encourage others, especially in Primary Care, and pscyhiatry to shuck the system and hang a shingle.
One of the things I am loving right now. I don't have to deal with these ludicrous metrics. I breath easier, and feel happier, able to simply practice. I do however personally review my active Tobacco Use Disorder patients and asses if I counseled cessation formally, offered treatments, etc. This is a real quality metric.

 

[Sushirolls]

I can't imagine a place that requires you to complete these and pays based on the result gives you the least bit of say in who gets assigned to your caseload.

Say hello to the intake people, schedulers, etc. Oh, you like mint truffles? I have to bring some by for you from ZYX.

 

[SourceOfDenial]

*sigh*, I expected a post with this sort of tone. From your reading of my post, what are you infering about my actual formulation and treatment of these patients?

Uh, I didn’t infer anything about your formulation and treatment from your first post, but from your second post I’m inferring the that you’re sensitive about your actual formulation and treatment of these patients.

 

[philosophize]

as others have said, it's really VA dependent and not only that, but also POSITION DEPENDENT. I emphasize that because spending the last 4 years in a VA. There are some great positions (partial hospitalization programs, residential substance abuse programs, and ECT). But most new psychiatrist get recruited for outpatient which here at my VA is a burnout job. Most outpt psych docs here carry 500+ patient case load and still get intakes weekly. Lots of team meetings that are largely a waste of time and on top of that documentation hassles to meet metrics. For the residential/partial programs, they are much more manageable with 20-25 patients that you see for 30 mins 1x/week, 1-2 team meetings per week, but that's it. So I would just scout out that particular position and that particular VA.

 

[Psychferlyfe3000]

Do VA jobs offer more job security for psychiatrist's than other jobs? If so, how so? The whole mid-level creep thing really has me nervous at times.

 

[reca]

Do VA jobs offer more job security for psychiatrist's than other jobs? If so, how so? The whole mid-level creep thing really has me nervous at times.

Idk, they eliminated physician moonlighters at our VA, hired a fresh psych NP instead. I looked her up, she did a one year program.

 

[comp1]

I'm not sure there's any job more secure than a VA job for pretty much anything. Where else are there physicians in a union after residency? Also, budgets don't really work the same as in the private or even academic sectors. If NPs are replacing moonlighters, it's likely more a patient flow issue or administrative issue than anything related to cost.

 

[Psychferlyfe3000]

I had no idea VA physicians were unionized. Interesting. Is that nationally or per Va?

 

[comp1]

VA (and the large majority of federal) employees who aren't supervisors, are in a union. It's national.

 

[Stagg737]

Do VA jobs offer more job security for psychiatrist's than other jobs? If so, how so? The whole mid-level creep thing really has me nervous at times.

Probably. It's harder to get sued, and you won't get fired for not meeting metrics (though you may get a significant paycut, happened to one of my former attendings). VA's have no problem hiring mid-levels as they're federal facilities and they don't require supervision even in states without FPA for mid-levels. That being said, I think the demand is high enough at most places that it's not a significant issue. One of the VAs we rotate through has nearly doubled their outpatient psych staff in the past 2 years went from 6-7 to now 12+) and they still struggle to get patients back in a timely manner. They may be hiring more mid-levels, but they're also still hiring plenty of psychiatrists (at least where I'm at).

 

[the5thelement]

Like everything else, there are pros and cons. The vacation days, compensation and health insurance are nice. Unfortunately,It seems that
the patients can have an incredible sense of entitlement and that coupled with benefits being tied to illness can result in frustration and loss of professional satisfaction(for the psychiatrist). In my opinion, you cannot put a price on that.

 

[AD04]

Probably. It's harder to get sued, and you won't get fired for not meeting metrics (though you may get a significant paycut, happened to one of my former attendings). VA's have no problem hiring mid-levels as they're federal facilities and they don't require supervision even in states without FPA for mid-levels. That being said, I think the demand is high enough at most places that it's not a significant issue. One of the VAs we rotate through has nearly doubled their outpatient psych staff in the past 2 years went from 6-7 to now 12+) and they still struggle to get patients back in a timely manner. They may be hiring more mid-levels, but they're also still hiring plenty of psychiatrists (at least where I'm at).

In that case, why hire psychiatrist at all? Hire a bunch of mid-levels and let them run wild. There's no consequence for messing up.

 

[comp1]

It's still very hard to fill both psych NP and psychiatrist positions. There are also some positions that tend to fit better into one category or another even if you technically could fill it with either. The nice thing is that decision is not cost driven.

 

[Stagg737]

In that case, why hire psychiatrist at all? Hire a bunch of mid-levels and let them run wild. There's no consequence for messing up.

Because this:

Unfortunately,It seems that the patients can have an incredible sense of entitlement and that coupled with benefits being tied to illness can result in frustration and loss of professional satisfaction(for the psychiatrist).

I've had a few patients who were pissed off that they were seeing a resident instead of "a real doctor" and had far less polite words about being seen by an NP. Another thing I've noticed is that the VA has numerous metrics in place and appears to value patient's opinions, but as you say there's pretty minimal consequences for doing the bare minimum or being slightly incompetent. That being said, the attendings I've worked with at my VA are great. Plus, the psychiatrists at our VA see more patients and have higher caseloads than the NPs do, at least at our VA. So the supposed savings would probably be minimal. Not that the gov cares about that anyway...

 

[AD04]

Because this:


I've had a few patients who were pissed off that they were seeing a resident instead of "a real doctor" and had far less polite words about being seen by an NP. Another thing I've noticed is that the VA has numerous metrics in place and appears to value patient's opinions, but as you say there's pretty minimal consequences for doing the bare minimum or being slightly incompetent. That being said, the attendings I've worked with at my VA are great. Plus, the psychiatrists at our VA see more patients and have higher caseloads than the NPs do, at least at our VA. So the supposed savings would probably be minimal. Not that the gov cares about that anyway...

If you work in the VA and patients rate you poorly and you don't meet metrics, what happens?

You can't get sued and you're on salary. So that means more work goes to those who are competent so why even try?

 

[Merovinge]

If you work in the VA and patients rate you poorly and you don't meet metrics, what happens?

You can't get sued and you're on salary. So that means more work goes to those who are competent so why even try?

Because you are taking care of real human beings? Not withstanding their service to the country.

 

[splik]

If you work in the VA and patients rate you poorly and you don't meet metrics, what happens?

You can't get sued and you're on salary. So that means more work goes to those who are competent so why even try?

Technically you can be sued if your conduct is so egregiously bad that the government can’t defend it (the intentional tort exception). But typically the FTCA does protect physicians who are government employees as the government would be sued instead. But VA physicians have been sued before so it is not impossible but not very likely.

 

[AD04]

Because you are taking care of real human beings? Not withstanding their service to the country.

Idealistic but not practical for system-wise implementation.

"If you would persuade, appeal to interest and not to reason."
- Benjamin Franklin

The structure of VA is deficient for retaining good psychiatrists and having them work hard. The structure is good for attracting lesser-training people who don't care too much about working.

 

[Stagg737]

If you work in the VA and patients rate you poorly and you don't meet metrics, what happens?

You can't get sued and you're on salary. So that means more work goes to those who are competent so why even try?

You can be reported to patient advocates or the director and have more punitive measures implemented like increased auditing and paperwork or given more pointless administrative duties. You can also have your pay docked, it happened to one of the former attendings at my VA because she wasn’t documenting correctly and RVUs weren’t being counted. So even though it is a salary position, their can be monetary punishments in certain situations.

 

[AD04]

You can be reported to patient advocates or the director and have more punitive measures implemented like increased auditing and paperwork or given more pointless administrative duties. You can also have your pay docked, it happened to one of the former attendings at my VA because she wasn’t documenting correctly and RVUs weren’t being counted. So even though it is a salary position, their can be monetary punishments in certain situations.

Good to hear. Do they only target physicians or do they target all employees from HR to nurses to whatnot?

VA staff doesn't have a reputation for working hard.

 

[Merovinge]

Good to hear. Do they only target physicians or do they target all employees from HR to nurses to whatnot?

VA staff doesn't have a reputation for working hard.

I think every doc who trained at a VA site has about 281309578 stories about VA nurses. Could make a heck of a tumblr page or a book.

 

[Stagg737]

Good to hear. Do they only target physicians or do they target all employees from HR to nurses to whatnot?

VA staff doesn't have a reputation for working hard.

I don't think they really target anyone and that unless something really egregious is done or someone gets enough complaints something may be done. I think prescribers and nurses are typically the ones who are reported. Maybe SW. Good luck reporting an admin in any healthcare system though.