What is considered a full outpt caseload?

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Hey everyone,

I graduated residency one year ago, started working for a group, left 3 months ago to pursue private practice. Currently I have 500 patients. I work 35 patient hours per week and do 20min follow ups, seeing about 3 new clients every day. It takes about 1.5mo to get in to see me right now.

Any ideas on what a reasonable cap should be? I fear the day where I’ll struggle to find open follow up slots for patients. So just want to make sure I get ahead of this by tapering down the intakes at some point. Just curious to hear other people’s experience with this.

Thanks in advance
 
Depends on acuity. If it takes current patients 1.5 months for an appt some of them will leave. Stable follow ups are good patients to have. You could consider blocking follow up time or pausing intakes
 
Yeah if you have people you really want to be seen in 4-6 weeks but you can't actually get them in, that's telling you you probably need to slow down intakes for a couple months and see where things shake out. Intakes tend to be the biggest issue since they block up an hour or more of your time, taking up 2-3 followup slots (2 for me, 3 for you it seems like), so 5 intakes in a week will cut off 10-15 follow slots that week. I'd probably cut intakes down to 1 a day for a month or two and see where things are.

Total caseload is highly dependent on things like how many followups you can see a day, how many clinical hours you work a week, how stable your overall patient panel is (you'll have a much bigger panel if your average followup is 12 weeks vs 4 weeks for instance), etc. so hard to give an overall number.

You also want to prioritize followups over new patients as you actually have an obligation to followup patients to see them in a timely manner if needed. You have no obligation to new patients (however desperate they make themselves out to be), as I often remind staff here when new patients bitch that they can't get into see me for 2 months (which isn't actually that bad for child....).
 
How does that math work? 35 hrs x 4 wks x 3 mo= 420. I could be making a bad assumption that your new patient slots are 60 min there. Did some patient follow you from the other practice? Are you cash only or insurance? If cash you're probably full or close to it now.
 
You essentially are full.
Restrict back your new consults to just 4 per week or so not the current 3 per day.

The other option, if insurance is taken, cut the lowest paying one. It'll open up slots. Build it back up again to current point. Then consider cutting the next worst insurance, repeat until you are happy with companies you are paneled with.
 
Sushirolls said:
You essentially are full.
Restrict back your new consults to just 4 per week or so not the current 3 per day.

The other option, if insurance is taken, cut the lowest paying one. It'll open up slots. Build it back up again to current point. Then consider cutting the next worst insurance, repeat until you are happy with companies you are paneled with.
Click to expand...
This 👍, stop taking your worst insurance, probably united I would bet!
 
Lower reimbursement from what I have seen though probably depends on location
 
trophyhusband said:
How does that math work? 35 hrs x 4 wks x 3 mo= 420. I could be making a bad assumption that your new patient slots are 60 min there. Did some patient follow you from the other practice? Are you cash only or insurance? If cash you're probably full or close to it now.
Click to expand...
Lots of patients followed me from the previous group I worked at. Probably about 250 did.
 
Thanks everyone for taking the time to respond to this and share their insights! I should pump the breaks a bit on intakes. It would sure be nice to not write 15-20 new intake notes per week.
 
Waaaaayyy too many intakes. Throttle them back with the main measure being if you have room to schedule follow ups on the time line you consider clinically appropriate and a little wiggle room for emergent issues.

There's no single magic number because the equilibrium point will be different depending on the acuity if your population and the average desired interval between visits.
 
You can't answer this in a simple manner.

I like doing what I do. I could do this 5.5 days a week and not feel overworked. My family, however, needs me more than this so I work 5 days a week.

When I get over a certain amount I notice I start forgetting details, patients that should be in the back of my head cause they have ongoing issues can't keep in the mental RAM. This happens at over 5.5 days a week.

At over 3 new patients a day I start to feel overworked. Ideally I have a mix of low to moderate intensity patients. If it's too many low intensities I feel like I'm not doing enough. To many moderate to severe can make the 5.5 days a week number less cause the candle's being lit at both ends.

It's taken years but I've figured out my own internal barometer.
 
And on the other end of the spectrum, I have 45 patients total and consider my caseload full in a cash only solo private practice. This is enough for me and keeps me satisfied and not overwhelmed with my work. Agree with @whopper and we all have our own internal barometer of how many patients is considered a full caseload.
 
I feel totally fine with 750ish unique patients seen in the last two years but some proportion of those have either been sent back to PCP or are stable annual follow-ups.

6 pt care hours * 5 days per week * 2 pts per hour * 6 weeks average follow-up time = 360 but that's if you keep them coming back q6wk. Again, plenty of patients who get spaced out with each interval where there's no change made--3 mo, 6 mo, annual/send to PCP. I have good access. Can get urgent pts in within the week usually and intake appointments around 4-6 weeks out not counting the couple of urgent intake slots.
 
850 patients seen so far withing 2 months of starting a private practice but i work with a medical assistant and there is an extrem shortage of psychiatrist both in PP and within the public hospital
Feels like i can still take some patients in
Hope that helps
 
Sikrouf said:
850 patients seen so far withing 2 months of starting a private practice but i work with a medical assistant and there is an extrem shortage of psychiatrist both in PP and within the public hospital
Feels like i can still take some patients in
Hope that helps
Click to expand...

What is going on in France....
 
Sikrouf said:
850 patients seen so far withing 2 months of starting a private practice but i work with a medical assistant and there is an extrem shortage of psychiatrist both in PP and within the public hospital
Feels like i can still take some patients in
Hope that helps
Click to expand...
Damn..
 
Sikrouf said:
850 patients seen so far withing 2 months of starting a private practice but i work with a medical assistant and there is an extrem shortage of psychiatrist both in PP and within the public hospital
Feels like i can still take some patients in
Hope that helps
Click to expand...
Are you working like 80 hours a week or seeing new patients for only 20 mins?
 
Sikrouf said:
850 patients seen so far withing 2 months of starting a private practice but i work with a medical assistant and there is an extrem shortage of psychiatrist both in PP and within the public hospital
Feels like i can still take some patients in
Hope that helps
Click to expand...
Wow. Good for you!
 
FlowRate said:
Are you working like 80 hours a week or seeing new patients for only 20 mins?
Click to expand...

I agree, those numbers are confusing if you are seeing all intakes on your own.

2 months = about 8 weeks
850 new / 8 weeks = about 106 new patients per week
106 new pts per week / 5 days per week = about 21 intakes per day

Seems like an incredibly high number! And the above does not count any follow ups.
 
FlowRate said:
Are you working like 80 hours a week or seeing new patients for only 20 mins?
Click to expand...
I m working 55 hours a week with the medical assistant working as much
the secretary asks patients how they are when they take an appointement, some have just been looking for a psychiatrist to renew prescribition for a year, others are looking for a full workup
there is a lot of psychologists around be in it in private practice or the public mental health system and patients understand quickly what are the limits of the medications are
new apointements are usually 30 mins and next sessions is (mandatory whenever possible) 30 mins with friends/family

for the patients with no psychologist or that have failed numerous psychotherapy i do some CBT - which of course is nothing like the "research" CBT and is a very degraded version but patients seems to be happy about it given that in France you can basically only get supportive or psychanalytic psychotherapy from psychologists
the only patients i find myself very dissatisfied with are the borderline ones for which i'm starting 2 DBT groups next month, one for adolescents and one for adults

i do some telepsych as there isnt much psychiatrist in France anywhere so i end up having patients coming from all around the country
i also do some child psychiatrist as some parents have been looking for 18 months for a child psychiatrist and it seems the shortage is even more severe there - obviously i tell the parents about my limited experience on the subject but when GP are giving risperidone or loxapine left and right it cant be much worse

2% of no show rate for the previous 2 months

Ill cut down to 45 hours a week next month to have save around 10 hours for reading articles/CME credits and stuff but so far i'm very please with having left the public hospital
 
Last edited:
FlowRate said:
Are you working like 80 hours a week or seeing new patients for only 20 mins?
Click to expand...
This gets back to the question which has been posted here before in various iterations....

Is it better for the patient to be seen by a psychiatrist who conducts a very abbreviated 20 minute eval or continue waiting for a psychiatrist in the future (tbd) who has room to do a proper 90 minute evaluation?
 
jbomba said:
This gets back to the question which has been posted here before in various iterations....

Is it better for the patient to be seen by a psychiatrist who conducts a very abbreviated 20 minute eval or continue waiting for a psychiatrist in the future (tbd) who has room to do a proper 90 minute evaluation?
Click to expand...

I also imagine the system itself is very different in France, in ways I probably don't understand anyway. One big one I could think of though is if there's essentially no malpractice liability, the concern around documentation and actual risk of doing such short evaluations is much lower.
 
jbomba said:
This gets back to the question which has been posted here before in various iterations....

Is it better for the patient to be seen by a psychiatrist who conducts a very abbreviated 20 minute eval or continue waiting for a psychiatrist in the future (tbd) who has room to do a proper 90 minute evaluation?
Click to expand...

i dont think you realise how bad the situation is

the public mental health sector has over 1 year of waiting list if you are a new outpatient
i'm the ONLY psychiatrist in private practice that takes new patients within a 100 miles radius
we've got several psychiatrist who are retiring in the coming year (4 at least), be it withing the private or public sector
the public mental health hospital is running with 3 psychiatrists currently - they're supposed to be 12

as far as child psychiatrist goes the public sector isnt taking any new appointements, there is not a single child psychiatrist in PP

the "90 mins evaluation psychiatrist" isnt happening in the futur, it is not happening at all


as far as malpractice goes it just doesnt exist in france basically, at least not in psych - even if you tried - for the better or worse but thats another debate
 
Sikrouf said:
i dont think you realise how bad the situation is

the public mental health sector has over 1 year of waiting list if you are a new outpatient
i'm the ONLY psychiatrist in private practice that takes new patients within a 100 miles radius
we've got several psychiatrist who are retiring in the coming year (4 at least), be it withing the private or public sector
the public mental health hospital is running with 3 psychiatrists currently - they're supposed to be 12

as far as child psychiatrist goes the public sector isnt taking any new appointements, there is not a single child psychiatrist in PP

the "90 mins evaluation psychiatrist" isnt happening in the futur, it is not happening at all


as far as malpractice goes it just doesnt exist in france basically, at least not in psych - even if you tried - for the better or worse but thats another debate
Click to expand...
Wow I sometimes don’t realize how good we have it here, if that’s how it is in France I cant even imagine other countries
 
Sikrouf said:
i dont think you realise how bad the situation is

the public mental health sector has over 1 year of waiting list if you are a new outpatient
i'm the ONLY psychiatrist in private practice that takes new patients within a 100 miles radius
we've got several psychiatrist who are retiring in the coming year (4 at least), be it withing the private or public sector
the public mental health hospital is running with 3 psychiatrists currently - they're supposed to be 12

as far as child psychiatrist goes the public sector isnt taking any new appointements, there is not a single child psychiatrist in PP

the "90 mins evaluation psychiatrist" isnt happening in the futur, it is not happening at all


as far as malpractice goes it just doesnt exist in france basically, at least not in psych - even if you tried - for the better or worse but thats another debate
Click to expand...

Yeah, I wasn't meaning to throw shade your way. It's an impossible situation. I would argue doing things the way you are doing them is the better option than the patient not being seen.
 
Sikrouf said:
i dont think you realise how bad the situation is

the public mental health sector has over 1 year of waiting list if you are a new outpatient
i'm the ONLY psychiatrist in private practice that takes new patients within a 100 miles radius
we've got several psychiatrist who are retiring in the coming year (4 at least), be it withing the private or public sector
the public mental health hospital is running with 3 psychiatrists currently - they're supposed to be 12

as far as child psychiatrist goes the public sector isnt taking any new appointements, there is not a single child psychiatrist in PP

the "90 mins evaluation psychiatrist" isnt happening in the futur, it is not happening at all


as far as malpractice goes it just doesnt exist in france basically, at least not in psych - even if you tried - for the better or worse but thats another debate
Click to expand...
Out of curiosity, how difficult is it for a psychiatrist from another country to come to France and practice? I hear so much about the physicians coming to the US from other countries, but I've never actually heard anything about US-trained, Canada-trained, or European psychiatrist moving to European countries.
 
forchinet121 said:
Wow I sometimes don’t realize how good we have it here, if that’s how it is in France I cant even imagine other countries
Click to expand...

Psychiatry as practiced in the U.S. isn't necessarily better, just different.

I had psychiatrists from developed and underdeveloped countries visit my program and what Sikrouf describes in France is the norm. The U.S. is the anomaly when it comes to medicine in general. It's not unusual for psychiatrists in other countries to see as many patients per day as a U.S. dermatologist sees. There is a much more severe shortage of psychiatrists (more emphasis on primary care), less/no third party lobbying (hence less/no EMR documentation requirement and less/no insurance meddling), reduced/no malpractice risk, reduced formulary list, more respect for doctors but less income.

It's hard to say psychiatry in the rest of the world is better or worse than psychiatry in the U.S. I see lots more homeless, actively psychotic people in American cities than other parts of the world. Is this because our psychiatry is worse? Or because U.S. patients have more rights? If people are less depressed and anxious in other countries, is it because of their psychiatric system or because other developed countries have better social supports and underdeveloped countries have better familial support? What is the NNT to improve outcomes if every psychiatrist changed their follow up visits to 60 minute visits? Or to 5 minutes?
 
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