Where are my community mental health center psychiatrists at?

[Coupd'Cat]

I'm putting out a call for other early career psychiatrists who have the joy and horror of working in a state-run community mental health center. It has been lonely as a freshly minted attending joining the ranks of psychiatrists whose average age is 70.

This is probably nothing new to the old-timers, and it probably could be worse. But I feel the burn because this is what passes as mental health care for people who are already told they don't deserve much.

1. The previous psychiatrist's philosophy was to get everyone on long-acting injectables whether they needed them or not so that he could see them as little as possible. One of my patients was on clozapine, olanzapine, and seroquel. Still having auditory hallucinations, suicidal thoughts, multiple ED visits and hospitalizations per month. He had CK to the 20000s at various points and was by the psychiatrist to "just don't exercise so much." Had two seizures. I took him off olanzapine and seroquel and began seeing him weekly. He hasn't had a hospitalization since.

2. Another one of my patients had the classic combo: clozapine, seroquel, invega trinza.

3. We are hemorrhaging therapists--one was hired several months after me and is leaving in a few weeks. He will be the sixth therapist to leave in the span of a year, leaving us with one permanent therapist for the entire clinic. When I ask management how we can improve retention, they say it's the staffs' fault for not wanting to get with the times.

4. Someone asked me to "pre-write" a PEC so that a team could take it with them and PEC a patient who they think "might get arrested again." I refused, and my patient was reported as non-compliant to parole officer, who is now ordering a warrant for his arrest.

When it's good it's good, when it's bad, it's because my patients can't seem to stop getting charged with felonies or getting evicted or getting called "psychotic" just because they are a person of color who doesn't want to talk.

I'd like to stay as long as I can, out of spite and duty (also the pay is fine).

So: How are you surviving? How are you being effective?

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[BACyeahyouknowme]

I couldn’t take it for long. CMH work felt like providing second-class care to the marginalized, for low wages.

I understand some people have a better experience, but in my area the jobs seemed to employ an army of clueless new-grad NPs and fresh-faced recent-grad psychiatrists who weren’t yet aware of how bad the jobs were, and how much better they were elsewhere.

That being said, I enjoyed the chaos and extreme patient presentations. I think a lot about getting back into CMH-land assuming I can find a job where the pay is competitive and my days don’t feel like I’m shoveling effort into a black hole all day.

It seems like some people make it work long-term by doing a hybrid of medical director duties and clinical work. The other group that makes it long-term seemed to be saints or super checked-out late-career people.

 

[Stagg737]

4. One member of my team asked me to "pre-write" a PEC so that they, a LCSW with full ability to write their own EC, could take it with them and PEC a patient who they think "might get arrested again." I refused, didn't think they needed to be PEC'd anyways, and said I would do a house visit instead. Before I could do so, they reported my patient as non-compliant with treatment to his parole officer, who is now ordering a warrant for his arrest.

I'm not familiar with the term PEC, but you're doing house visits? For CMH? Not trying to sound insulting, but are you out of your mind?

 

[WisNeuro]

I'm not familiar with the term PEC, but you're doing house visits? For CMH? Not trying to sound insulting, but are you out of your mind?

Physician's Emergency Certificate? Essentially a 72-hour hold in certain jurisdictions.

 

[calvnandhobbs68]

I'm not familiar with the term PEC, but you're doing house visits? For CMH? Not trying to sound insulting, but are you out of your mind?

Some community mental health centers absolutely do home/shelter visits. I worked in a clinic for a couple years in residency that was primarily homeless/low income patients and the psychiatrists/NPs there did home visits with the social workers not infrequently (and as far as I know they weren't part of an ACT team or something, that was separate).

Also props to you OP to doing work that's absolutely under-recognized, under-resourced and often underpaid. It's a rough environment for sure but as you're already finding out being even semi-competent can make a big difference for some of these people that nobody else seems to care much about.

 

[When is graduation again?]

I am right there with you! Thank you for this post. It can be pretty isolating working in CHMC/ACT fresh out of residency. Here are a few of my gems.

1) There were almost NO labs done on any patients in the 3 years before I came (other than clozaril CBCs). I'm talking patients on the team since 2016 on LAIs without a single HgbA1c. In my month 2, I luckily caught on to the fact a patient on Invega Sustenna had previous stage 3 CKD diagnosis from an ED visit for chest pain. I had labs done and she had a eGFR of 14. Invega levels were 2-3x max recommended blood levels and I'm not even convinced she has schizophrenia.

2) DOJ and our lower acuity community teams (influenced by DOJ) try to sneak us clearly antisocial, substance abusing patients. We block them, but last week they tried to slip us one and added him to our team without our approval. We did a screening appointment in the office and dude literally threatened to kill me twice and was aggressive/hostile the whole appointment. He didn't even know why he was being transferred to us and didn't even want to leave his former community treatment team. We kicked that right back to them, but not being able to trust people who are supposed to be your co-workers is rough.

3) Management is terrible. Too much bs office politics that destroy team moral. We have a fully built, stable team and everyone is mostly dedicated, but management is letting office admins with personality issues chase away both my nurses.

Personally, I'm trying to stay at least a year because I really love the work, my team, and the patients. But the b.s. makes it really difficult. I'd like to say I'm effective at advocating for my patients and building relationships with them. Our patient hospitalizations have also been reduced substantially and I've improved a lot of intake procedures and am working on improving our subpar pharmacy situation. But looking at my former co-residents experiences out of residency, life could be so much easier.

 

[Stagg737]

Some community mental health centers absolutely do home/shelter visits. I worked in a clinic for a couple years in residency that was primarily homeless/low income patients and the psychiatrists/NPs there did home visits with the social workers not infrequently (and as far as I know they weren't part of an ACT team or something, that was separate).

Also props to you OP to doing work that's absolutely under-recognized, under-resourced and often underpaid. It's a rough environment for sure but as you're already finding out being even semi-competent can make a big difference for some of these people that nobody else seems to care much about.

I could see going to shelters or somewhere else where there is some form of a secure environment, but into patient's homes? There's a difference between a SW going to their homes to assist with needs and us going for a med check/therapy. I knew enough docs who have been assaulted and been threatened myself by patients enough that I can't imagine ever doing this.

2) DOJ and our lower acuity community teams (influenced by DOJ) try to sneak us clearly antisocial, substance abusing patients. We block them, but last week they tried to slip us one and added him to our team without our approval. We did a screening appointment in the office and dude literally threatened to kill me twice and was aggressive/hostile the whole appointment. He didn't even know why he was being transferred to us and didn't even want to leave his former community treatment team. We kicked that right back to them, but not being able to trust people who are supposed to be your co-workers is rough.

And this is the perfect example of why I feel this is a bad idea. A lot of personality issues in CMHC populations (even if they also have some other SPMI) makes being outside of at least a partially controlled environment too dangerous.

 

[When is graduation again?]

And this is the perfect example of why I feel this is a bad idea. A lot of personality issues in CMHC populations (even if they also have some other SPMI) makes being outside of at least a partially controlled environment too dangerous.

That's 100% why we screen everyone and won't be bullied into taking inappropriate patients. Most of my patients are sweet and honestly chronically victimized by others. I have 1 or 2 that I have to be cautious of, under certain circumstances. But overall, there's no work I like nearly as much as ACT work. It's the whole reason I chose psychiatry. It's certainly not for everyone and you have to be on guard sometimes, but the impact on individual patients' lives is huge, if you have the right team.

 

[Stagg737]

That's 100% why we screen everyone and won't be bullied into taking inappropriate patients. Most of my patients are sweet and honestly chronically victimized by others. I have 1 or 2 that I have to be cautious of, under certain circumstances. But overall, there's no work I like nearly as much as ACT work. It's the whole reason I chose psychiatry. It's certainly not for everyone and you have to be on guard sometimes, but the impact on individual patients' lives is huge, if you have the right team.

Maybe my experience isn't broad enough. The CMHCs I worked with in residency had a high percentage of either substance abusers/seekers or severe personality pathology and I found that probably 50%+ of my patients primary issues were one of those two problems. Before the clinic I worked with specifically made a policy of no longer prescribing Xanax, that percent was higher. I could see it being very rewarding when working with the right patients, and despite that this was actually my favorite outpatient clinic, I just can't imagine being able to feel safe seeing those patients outside of a controlled setting.

 

[Coupd'Cat]

I'm not familiar with the term PEC, but you're doing house visits? For CMH? Not trying to sound insulting, but are you out of your mind?

Maybe my experience isn't broad enough. The CMHCs I worked with in residency had a high percentage of either substance abusers/seekers or severe personality pathology and I found that probably 50%+ of my patients primary issues were one of those two problems. Before the clinic I worked with specifically made a policy of no longer prescribing Xanax, that percent was higher. I could see it being very rewarding when working with the right patients, and despite that this was actually my favorite outpatient clinic, I just can't imagine being able to feel safe seeing those patients outside of a controlled setting.

I think you're correct and that's probably the difference. Most of my patients have PTSD and/or psychosis. The house visits I've made were for various reasons--a young man who had been stabbed and was afraid to leave his house to come into the clinic, another man living in a group home starting to isolate himself and was afraid of the police in front of our clinic, etc. I'm always going out with a case manager or nurse, not alone. Sometimes it's to see for myself someone's living conditions. I also do it to build credibility with the team.

A few times, it's when someone's missed their appointments. An hour of my time going out sometimes gets them to come in and not leave a gap in my schedule as a no show. I think it's because they consider it harassment and would like me to stop going out and invading their space.

I also did home visits while in residency, which might not be common. This was more for seeing patients who were homeless or living in encampments. Most of the time people would not have been seen otherwise, and relationships did build up over time. Patients were sometimes protective of us. We knew when to walk away and just come back another day.

Structured settings such as the ED and inpatient units were where I felt more wary, since there was nowhere for me or the patient to run away to. I was also their obvious target, if I was telling them they couldn't leave or had taken hours to come see them. When any of us feel trapped, that's when violence happens.

 

[Coupd'Cat]

I couldn’t take it for long. CMH work felt like providing second-class care to the marginalized, for low wages.

I understand some people have a better experience, but in my area the jobs seemed to employ an army of clueless new-grad NPs and fresh-faced recent-grad psychiatrists who weren’t yet aware of how bad the jobs were, and how much better they were elsewhere.

That being said, I enjoyed the chaos and extreme patient presentations. I think a lot about getting back into CMH-land assuming I can find a job where the pay is competitive and my days don’t feel like I’m shoveling effort into a black hole all day.

It seems like some people make it work long-term by doing a hybrid of medical director duties and clinical work. The other group that makes it long-term seemed to be saints or super checked-out late-career people.

If you ever go back, we can be in a support group together. What did you move on to?

 

[Coupd'Cat]

I am right there with you! Thank you for this post. It can be pretty isolating working in CHMC/ACT fresh out of residency. Here are a few of my gems.

1) There were almost NO labs done on any patients in the 3 years before I came (other than clozaril CBCs). I'm talking patients on the team since 2016 on LAIs without a single HgbA1c. In my month 2, I luckily caught on to the fact a patient on Invega Sustenna had previous stage 3 CKD diagnosis from an ED visit for chest pain. I had labs done and she had a eGFR of 14. Invega levels were 2-3x max recommended blood levels and I'm not even convinced she has schizophrenia.

Here for you, too. Also, my good lord. What ended up happening?

2) DOJ and our lower acuity community teams (influenced by DOJ) try to sneak us clearly antisocial, substance abusing patients. We block them, but last week they tried to slip us one and added him to our team without our approval. We did a screening appointment in the office and dude literally threatened to kill me twice and was aggressive/hostile the whole appointment. He didn't even know why he was being transferred to us and didn't even want to leave his former community treatment team. We kicked that right back to them, but not being able to trust people who are supposed to be your co-workers is rough.

Good on you. I'll likely need to borrow your backbone at some point.

3) Management is terrible. Too much bs office politics that destroy team moral. We have a fully built, stable team and everyone is mostly dedicated, but management is letting office admins with personality issues chase away both my nurses.

Here, too. 💩 floats!! At any sign of my asking a question or challenging middle management, they 1) ask if I need more online training o2) respond to an email by asking to take up my time with a meeting which inevitably consists of them trashing the rest of the staff and trying to convince me that I'm not seeing what I'm seeing 3) call in my medical director and their upper management to tell me "it's always been bad."

Personally, I'm trying to stay at least a year because I really love the work, my team, and the patients. But the b.s. makes it really difficult. I'd like to say I'm effective at advocating for my patients and building relationships with them. Our patient hospitalizations have also been reduced substantially and I've improved a lot of intake procedures and am working on improving our subpar pharmacy situation. But looking at my former co-residents experiences out of residency, life could be so much easier.

Agreed. Let's both try to make it to a year. We'll meet here again.

 

[alina_s]

There are better and worse functioning CMHC’s. I worked in MO right out of training and in neighboring KY either a large group of CMHC’s or maybe statewide had agreed not to prescribe benzo’s. Either way, there was some migration, and the MO legislature had also taken a stand against creating a PDMP. The CMHC I worked at had a lot of social workers who seemed to have specialized in management- they had the billing and finances down, which are important- but didn’t seem to appreciate the time required for assessment and care coordination between different parts of the team and were pretty clueless about safety. I often went into intakes with no background and the psychiatry assessment was often the first contact in the system. They’d had so much trouble recruiting and retaining over the years that patients were used to being able to say what they wanted and receive it. Communication with the numerous hospitals in the area was also poor. I filled my NHSC obligation but just felt like I wasn’t going to be able to make enough change to make it safer or more rewarding for me, so I left as soon as I could.
I’m at a CMHC now, after a break from this kind of work, and don’t plan to move on. I like the population, even if gains are slow and small. The place I work now has its quirks- it may have too much management and too many processes for change- but it’s responsive to us, as well as to patients. They allow for much better communication with therapists and case manager. Case management could use a lot of improvement here. We’re part of a whole hospital system and probably 60% of our patients get their primary care in the system. With more experience, I think my tolerance for working with incomplete information is increased. This system is also better-functioning than the last one, even if communication from outside hospitals is still terrible.
In training and after, I also worked for a few CMHC’s (not part of the university) that were functioning well. What I admired about those programs was that they managed to use psychiatrists as consultants. In one, I just met with the clinicians for a monthly meeting to review cases and they occasionally referred cases out for evaluation. In two other programs, teens had to be engaged with their therapists and case managers for a month or two, we reviewed referrals in a meeting, and case managers brought them to the intakes and follow ups.

 

[When is graduation again?]

Maybe my experience isn't broad enough. The CMHCs I worked with in residency had a high percentage of either substance abusers/seekers or severe personality pathology and I found that probably 50%+ of my patients primary issues were one of those two problems. Before the clinic I worked with specifically made a policy of no longer prescribing Xanax, that percent was higher. I could see it being very rewarding when working with the right patients, and despite that this was actually my favorite outpatient clinic, I just can't imagine being able to feel safe seeing those patients outside of a controlled setting.

Your experience is accurate for office based CHMCs. However, the ACT model was created for people with primary psychosis, bipolar, and in select cases MDD. Personality and substance disorders aren't appropriately treated with ACT and put our safety at risk, since we're seeing people in the community. That's why screening is pivotal. If we miss something in the screening, I have no problem stepping people down if safety becomes an issue.

 

[When is graduation again?]

Here for you, too. Also, my good lord. What ended up happening?

Good on you. I'll likely need to borrow your backbone at some point.

Here, too. 💩 floats!! At any sign of my asking a question or challenging middle management, they 1) ask if I need more online training o2) respond to an email by asking to take up my time with a meeting which inevitably consists of them trashing the rest of the staff and trying to convince me that I'm not seeing what I'm seeing 3) call in my medical director and their upper management to tell me "it's always been bad."

Agreed. Let's both try to make it to a year. We'll meet here again.

I switched that patient to Haldol Dec. Took about 3-4 months for her Invega levels to get to the point that I could make the switch. Unfortunately, now she's in need of dialysis, eGFR is 8. But she won't get the fistula because her family members who had dialysis in the past died...We're working with her on this, but she's IDD with poor family support, so we're making slow progress.

Wow, your management sounds like a different kind of terrible. Mine mainly leaves me alone. They might ask my team lead why I won't sign forms indicating I've seen patients before I actually have seen the patient because "all the other doctors do it", but don't bring that to me. My management mainly ignores problems until they blow up and threaten team cohesion.

I have about 4 months left till I hit my year mark! Ideally, the b.s. improves, so I won't have to leave because I really like the work. Good luck making it to a year!

 

[When is graduation again?]

There are better and worse functioning CMHC’s. I worked in MO right out of training and in neighboring KY either a large group of CMHC’s or maybe statewide had agreed not to prescribe benzo’s. Either way, there was some migration, and the MO legislature had also taken a stand against creating a PDMP. The CMHC I worked at had a lot of social workers who seemed to have specialized in management- they had the billing and finances down, which are important- but didn’t seem to appreciate the time required for assessment and care coordination between different parts of the team and were pretty clueless about safety. I often went into intakes with no background and the psychiatry assessment was often the first contact in the system. They’d had so much trouble recruiting and retaining over the years that patients were used to being able to say what they wanted and receive it. Communication with the numerous hospitals in the area was also poor. I filled my NHSC obligation but just felt like I wasn’t going to be able to make enough change to make it safer or more rewarding for me, so I left as soon as I could.
I’m at a CMHC now, after a break from this kind of work, and don’t plan to move on. I like the population, even if gains are slow and small. The place I work now has its quirks- it may have too much management and too many processes for change- but it’s responsive to us, as well as to patients. They allow for much better communication with therapists and case manager. Case management could use a lot of improvement here. We’re part of a whole hospital system and probably 60% of our patients get their primary care in the system. With more experience, I think my tolerance for working with incomplete information is increased. This system is also better-functioning than the last one, even if communication from outside hospitals is still terrible.
In training and after, I also worked for a few CMHC’s (not part of the university) that were functioning well. What I admired about those programs was that they managed to use psychiatrists as consultants. In one, I just met with the clinicians for a monthly meeting to review cases and they occasionally referred cases out for evaluation. In two other programs, teens had to be engaged with their therapists and case managers for a month or two, we reviewed referrals in a meeting, and case managers brought them to the intakes and follow ups.

Your current CHMC seems like they're trying to do right by staff and patients at least. Hopefully, your current CHMC ends up being a great fit for you long-term. My mentor, who introduced me to ACT in med school, jumped from ACT team to ACT team until he found a situation that worked well. He's been at his current organization at least 8-10 years now. I may end up jumping around a bit too, until I find the right situation.

 

[TheRightMedication]

My experience in community psychiatry resulted in a cash only private practice, though I've softened that and now take some insurance.

 

[MedMan80]

not a CMH psychiatrist but I may as well be. Our local CMH is hemorrhaging patients for med management to our hospital psych clinic, issue is we don't have the resources that they do (no therapy/case management availability). The CMH prescribers make the care there so stinky that patients hate going there and come to us to transfer care.

I always wonder if the benefits are good at the CMH clinics, i believe our place gives nice insurance/access to state pension, although I'm sure the salary isn't as good as a hospital employed gig.

 

[TheRightMedication]

I'm not sure why anyone would go to a CMH, either to work or to get services. Perhaps I've only had unimpressive experiences, but in CMH's I found only unhappy staff with high turnover, and unhappy underserved patients.

Better to make money independently and do some charity work at free clinics, if you ask me.

Edit- As to the OP's question of how to survive, I survived by abandoning the model. As to efficacy, I hope to address that more fully as I develop my private practice.

 

[Merovinge]

I'm not sure why anyone would go to a CMH, either to work or to get services. Perhaps I've only had unimpressive experiences, but in CMH's I found only unhappy staff with high turnover, and unhappy underserved patients.

Better to make money independently and do some charity work at free clinics, if you ask me.

Edit- As to the OP's question of how to survive, I survived by abandoning the model. As to efficacy, I hope to address that more fully as I develop my private practice.

There are world beaters who can not only do the work but evolve the organization to some extent from the inside and make a profound difference in the life of the those who have the least. That's essentially my definition of a hero. Now I am no hero and couldn't do it myself, but for those with disposition and ability to do this work they should be praised and lauded, not encouraged to leave the broken system IMO.

 

[TheRightMedication]

There are world beaters who can not only do the work but evolve the organization to some extent from the inside and make a profound difference in the life of the those who have the least. That's essentially my definition of a hero. Now I am no hero and couldn't do it myself, but for those with disposition and ability to do this work they should be praised and lauded, not encouraged to leave the broken system IMO.

I argue such heroes stabilize the system just enough to keep it going. Here I mean not only CMH's and local governments as systems, but also society as a whole.

I know there are patients with an axis I diagnosis who require, and can generally get, treatment at a CMH. Yet there also those with other-than-axis-I issues who get disability payments and psychotropics as part of an informal social contract to keep them from being disruptive to society.

I appreciate my theoretical concerns do nothing constructive to help the humans who come to a CMC for help, and need help, and have so little recourse.

I suppose I only mean to say that I, personally, did not have the stomach for such a role in such a system.

 

[annoyedpsychiatrist]

spent a year in the community mental health setting. Loved the patients (most of them). hated admin. Hated responsibility of having 5 midlevels to supervise when half of them were incredibly inexperienced. Felt like my name was also being attached to shady things. Admin was rude/condescending and would blatantly lie. Got out after a year, couldnt do it anymore. I make more money now for half the work. I was seeing around 20 high acuity patients a day+ on the phone for complex cases+ seeing "emergency evals"

these places seem to be run by shady businessmen

 

[annoyedpsychiatrist]

I'm putting out a call for other early career psychiatrists who have the joy and horror of working in a state-run community mental health center. It has been lonely as a freshly minted attending joining the ranks of psychiatrists whose average age is 70. Our oldest practicing psychiatrist is in his 90s.

This is probably nothing new to the old-timers, and it probably could be worse. But I feel the burn because this is what passes as mental health care for people who are already told they don't deserve much.

1. The previous psychiatrist's philosophy was to get everyone on long-acting injectables whether they needed them or not so that he could see them as little as possible. One of my patients was on clozapine, olanzapine, and seroquel. Still having auditory hallucinations, suicidal thoughts, multiple ED visits and hospitalizations per month. He had CK to the 20000s at various points and was by the psychiatrist to "just don't play basketball so much" and was encouraged to confine himself in his bed. Had two seizures. I took him off olanzapine and seroquel and began seeing him weekly. He hasn't had a hospitalization since.

2. Another one of my patients had the classic combo: clozapine, seroquel, invega trinza.

3. We are hemorrhaging therapists--one was hired several months after me and is leaving in a few weeks. He will be the sixth therapist to leave in the span of a year, leaving us with one permanent therapist for the entire clinic. When I ask management how we can improve retention, they say it's the staffs' fault for not wanting to get with the times.

4. One member of my team asked me to "pre-write" a PEC so that they, a LCSW with full ability to write their own EC, could take it with them and PEC a patient who they think "might get arrested again." I refused, didn't think they needed to be PEC'd anyways, and said I would do a house visit instead. Before I could do so, they reported my patient as non-compliant with treatment to his parole officer, who is now ordering a warrant for his arrest.

When it's good it's good, when it's bad, it's because my patients can't seem to stop getting charged with felonies or getting evicted or getting called "psychotic" just because they are a person of color who doesn't want to talk by people who have worked in the mental health field for longer than I've been alive and couldn't recognize psychosis if it punched them in the stomach and sat on their face

I'd like to stay as long as I can, out of spite and duty (also the pay is great).

So: How are you surviving? How are you being effective?

also just curious, what are you making? i thought i made good money doing it, and now im making way more now for less stress

 

[TheRightMedication]

also just curious, what are you making? i thought i made good money doing it, and now im making way more now for less stress

There's no question that the money at a CMH is fair to low, and there are better gigs to be had.

Is the CMH work worth the middling salary, that's the question.

 

[R. Matey]

Is the CMH work worth the middling salary, that's the question.

Can't speak to psychiatry, but for therapists, the wages are a pittance even by master's level standards (the therapy providers whom CMHCs largely employ). I'm not necessarily saying it's better elsewhere in terms of overall organizational culture, but if you can be paid better to take the same flack, why wouldn't you?

 

[annoyedpsychiatrist]

i make around 30-40k more a year (factoring in difference in state taxes too) working at a significantly better job with overall better system. The culture was terrible at the CMH. I have not missed it one day, lol. They will feed you this BS that they can only afford to pay psychiatrists this set number, but then they get millions in grants that goes to questionable places.

 

[clausewitz2]

Can't speak to psychiatry, but for therapists, the wages are a pittance even by master's level standards (the therapy providers whom CMHCs largely employ). I'm not necessarily saying it's better elsewhere in terms of overall organizational culture, but if you can be paid better to take the same flack, why wouldn't you?

Presumably the master's level people only really tolerate it because they can work there without having a full license and not infrequently get required supervision comped (of variable quality). I definitely don't understand why any therapists stick around in environments like that apart from the fact that you can really, really phone it in without consequences.

 

[R. Matey]

Presumably the master's level people only really tolerate it because they can work there without having a full license and not infrequently get required supervision comped (of variable quality). I definitely don't understand why any therapists stick around in environments like that apart from the fact that you can really, really phone it in without consequences.

100%. Years ago, CMHCs were viewed in my locale as the primary training ground for a post-master's, pre-licensed clinician--a de facto residency of sorts just by virtue of being willing to take on so many pre-licensed master's trainees. From my vantage point, it was seen as a step into private practice, larger group practice, or some other better paying healthcare system. IME, those who stayed were either the heroes mentioned upthread or just a few sticks short of a bundle.

 

[DJKitty]

So, I may be the outlier, but I work at a FQHC and I really like it there. I am getting paid more than I would be in academia and I get to practice geriatric psychiatry 100% which is rare. I like the organization I work for and it has a great culture. I have good benefits and for the most part really good patients. We have a lot of resources and I feel like I can provide quality, evidenced-base care for my patients. I don't have to supervise mid-levels and can practice the way I would like to practice. Just wanted to chime in and offer a positive review of community mental health in case any residents/fellows are reading this thread 🙂

 

[TheRightMedication]

So, I may be the outlier, but I work at a FQHC and I really like it there. I am getting paid more than I would be in academia and I get to practice geriatric psychiatry 100% which is rare. I like the organization I work for and it has a great culture. I have good benefits and for the most part really good patients. We have a lot of resources and I feel like I can provide quality, evidenced-base care for my patients. I don't have to supervise mid-levels and can practice the way I would like to practice. Just wanted to chime in and offer a positive review of com munity mental health in case any residents/fellows are reading this thread 🙂

An FQHC is, in my view, a viable alternative to a traditional CMH. Glad to hear of your experience.

 

[MedMan80]

I mentioned this before, but aren't some FQHC eligible for federal tort insurance? (hard to get sued)

 

[R. Matey]

So, I may be the outlier, but I work at a FQHC and I really like it there. I am getting paid more than I would be in academia and I get to practice geriatric psychiatry 100% which is rare. I like the organization I work for and it has a great culture. I have good benefits and for the most part really good patients. We have a lot of resources and I feel like I can provide quality, evidenced-base care for my patients. I don't have to supervise mid-levels and can practice the way I would like to practice. Just wanted to chime in and offer a positive review of community mental health in case any residents/fellows are reading this thread 🙂

An FQHC is, in my view, a viable alternative to a traditional CMH. Glad to hear of your experience.

Mind explaining what this is to an outsider? I'm interested in models that service this population adequately.

 

[TheRightMedication]

What is a Federally Qualified Health Center (FQHC)? — FQHC Associates

What is a Federally Qualified Health Center? According to HRSA, FQHCs qualify for funding under Section 330 of the Public Health Service Act, serve an underserved area or population, offer a sliding fee scale, and have a governing board of directors, among other things.

www.fqhc.org

It's a model, a staff structure, and a funding structure. The core of it is a case manager type attached to a PCP office who identifies and manages 100? Or so cases in that office who need psych services. Those cases see that person for limited therapy. That staff person also refers them to a 0.3 or so FTE psychiatrist who sees those referrals and also sees consults from the PCP. The objective for the shrink is to return them to the PCP's care quickly, or refer out.

There's special billing codes for it.

The above is from remote memory so I'm probably off in some places.

 

[Coupd'Cat]

also just curious, what are you making? i thought i made good money doing it, and now im making way more now for less stress

The starting salary at my clinic is $230K and goes up to $300K for regular staff psychiatrists. I asked to be paid by the hour in return for not having benefits (I used my spouse's health insurance and save for retirement on my own), which ends up being about $350K. I didn't think I'd want to stick around long enough to be vested into the pension program. Who knows if the world will still be standing by then.

The stress gets more manageable with time, and the particular clinic I work in right now has great nurses. It's good enough and interesting. I have some hope it will get better, and not much hope it would be much better elsewhere, just different. Pros of the state CMHC: hard to get sued (as my predecessor clearly realized), interesting, paper charts (I hate SmartText or whatever the hell those EMR boxes are called), gallows humor.

I considered a local FQHC (pressure on meeting the bottom line), an academic position (the institution takes its blood money, insular, would have to interact with academics), and a local jail (police make me nervous, too many limits on how I would want to practice). When I feel more settled and have more saved up, I'll start a small private practice on the side for variety and to feel less like a cog. Instead, I'll be a part-time cog. Thank you for the posts so far.

 

[Coupd'Cat]

I argue such heroes stabilize the system just enough to keep it going. Here I mean not only CMH's and local governments as systems, but also society as a whole.

I think about this all the time. Foster care --> jail --> CMHC. I wonder about who needs to believe that my patient can separate from the institution first, myself/the psychiatrist or them--or both. I also wonder what the institution is supposed to be replacing or filling the absence of.

 

[TheFuture_22]

The CMHC I work at is actually pretty well run. We only employ psychiatrists and have residents that we supervise as well. We have an RN that all they do is answer patient phone calls as well as another nurse that only does prior authorizations, LAIs, labs, and vitals (if needed). We also have a day treatment program that is attached to the clinic, so we can pull a patient that is struggling from there for a quick visit or go grab them when it is time for a scheduled visit. We also have care coordinators, SWers, in house pharmacy with multiple pharmacists, in house security staff, and therapists. We even have a medical clinic that is in the same building and has a couple MDs (and a few mid-levels) and uses the same EMR which is nice. The support staff is so competent that probably only 10% or less of the phone calls that come through require that I call the patient back. We have 30 minute follow ups and 1 hr new patient visits as well as 1 hour of admin time daily included in the salary. We do go through a lot of therapists which is one negative. I think we might be a bit of an outlier when it comes to CMHCs, but I do think there are likely other well run CMHCs out there if you look hard enough. Even with all this, the job is still very difficult and stressful at times because of how ill the patient population is. I wouldn’t trade my current job for anything though as it’s very rewarding.

 

[annoyedpsychiatrist]

The starting salary at my clinic is $230K and goes up to $300K for regular staff psychiatrists. I asked to be paid by the hour in return for not having benefits (I used my spouse's health insurance and save for retirement on my own), which ends up being about $350K. I didn't think I'd want to stick around long enough to be vested into the pension program. Who knows if the world will still be standing by then.

The stress gets more manageable with time, and the particular clinic I work in right now has great nurses. It's good enough and interesting. I have some hope it will get better, and not much hope it would be much better elsewhere, just different. Pros of the state CMHC: hard to get sued (as my predecessor clearly realized), interesting, paper charts (I hate SmartText or whatever the hell those EMR boxes are called), gallows humor.

I considered a local FQHC (pressure on meeting the bottom line), an academic position (the institution takes its blood money, insular, would have to interact with academics), and a local jail (police make me nervous, too many limits on how I would want to practice). When I feel more settled and have more saved up, I'll start a small private practice on the side for variety and to feel less like a cog. Instead, I'll be a part-time cog. Thank you for the posts so far.

fairly good pay. Were roughly the same amount in pay terms, but my patient load is very reasonable (30 min f/u, 1 hour intakes), Was seeing 20+ patients a day at community psych job last job. Not even counting supervision duties. I would go crazy with paper charts though. my handwriting is awful, i wouldnt be able to read my notes lol. Most community psych places have sovereign immunity right? my last one did i think. my current job actually has it. That is a nice perk.

 

[smalltownpsych]

The CMHC I work at is actually pretty well run. We only employ psychiatrists and have residents that we supervise as well. We have an RN that all they do is answer patient phone calls as well as another nurse that only does prior authorizations, LAIs, labs, and vitals (if needed). We also have a day treatment program that is attached to the clinic, so we can pull a patient that is struggling from there for a quick visit or go grab them when it is time for a scheduled visit. We also have care coordinators, SWers, in house pharmacy with multiple pharmacists, in house security staff, and therapists. We even have a medical clinic that is in the same building and has a couple MDs (and a few mid-levels) and uses the same EMR which is nice. The support staff is so competent that probably only 10% or less of the phone calls that come through require that I call the patient back. We have 30 minute follow ups and 1 hr new patient visits as well as 1 hour of admin time daily included in the salary. We do go through a lot of therapists which is one negative. I think we might be a bit of an outlier when it comes to CMHCs, but I do think there are likely other well run CMHCs out there if you look hard enough. Even with all this, the job is still very difficult and stressful at times because of how ill the patient population is. I wouldn’t trade my current job for anything though as it’s very rewarding.

A well run day treatment program and multiple levels of support and flexibility to implement those is essential. Would probably have less therapist turnover if you had a good psychologist running things. We tend to be a little better at analyzing and improving complex systems involving complex behaviors and social dynamics and also has the first hand understanding of how challenging therapy is.

 

[Merovinge]

The CMHC I work at is actually pretty well run. We only employ psychiatrists and have residents that we supervise as well. We have an RN that all they do is answer patient phone calls as well as another nurse that only does prior authorizations, LAIs, labs, and vitals (if needed). We also have a day treatment program that is attached to the clinic, so we can pull a patient that is struggling from there for a quick visit or go grab them when it is time for a scheduled visit. We also have care coordinators, SWers, in house pharmacy with multiple pharmacists, in house security staff, and therapists. We even have a medical clinic that is in the same building and has a couple MDs (and a few mid-levels) and uses the same EMR which is nice. The support staff is so competent that probably only 10% or less of the phone calls that come through require that I call the patient back. We have 30 minute follow ups and 1 hr new patient visits as well as 1 hour of admin time daily included in the salary. We do go through a lot of therapists which is one negative. I think we might be a bit of an outlier when it comes to CMHCs, but I do think there are likely other well run CMHCs out there if you look hard enough. Even with all this, the job is still very difficult and stressful at times because of how ill the patient population is. I wouldn’t trade my current job for anything though as it’s very rewarding.

That's awesome, your setup is one of the only things that would make me ever consider doing adult psychiatry again. You guys need to be making a manual for your care system and collect data on it to help propagate it elsewhere.

 

[milesed]

The CMHC I work at is actually pretty well run. We only employ psychiatrists and have residents that we supervise as well. We have an RN that all they do is answer patient phone calls as well as another nurse that only does prior authorizations, LAIs, labs, and vitals (if needed). We also have a day treatment program that is attached to the clinic, so we can pull a patient that is struggling from there for a quick visit or go grab them when it is time for a scheduled visit. We also have care coordinators, SWers, in house pharmacy with multiple pharmacists, in house security staff, and therapists. We even have a medical clinic that is in the same building and has a couple MDs (and a few mid-levels) and uses the same EMR which is nice. The support staff is so competent that probably only 10% or less of the phone calls that come through require that I call the patient back. We have 30 minute follow ups and 1 hr new patient visits as well as 1 hour of admin time daily included in the salary. We do go through a lot of therapists which is one negative. I think we might be a bit of an outlier when it comes to CMHCs, but I do think there are likely other well run CMHCs out there if you look hard enough. Even with all this, the job is still very difficult and stressful at times because of how ill the patient population is. I wouldn’t trade my current job for anything though as it’s very rewarding.

My set up is similar to your and I love it. I moonlighted at a few different state-run CMHC's in residency and liked what I saw there, love the underserved population. We don't have a medical clinic and the times for appointments is shorter, but the pay is way higher than the ones that gave more time. I do supervise 4 ARNP's and some ARNP students. After about a year they are well-trained and very independent, but do staff difficult cases with me. We also have a Crisis Unit, 4 week residential substance treatment facility, day treatment for kids, IOP, great nurses and admin support.

 

[When is graduation again?]

Just to add (for residents/students interested in community psych), not all jobs are 20+ patients in 15 minute slots. My ACT job is like 3-4 patients per day currently. I will probably avg 5 per day once the patient panel is maxed out. Hours are very flexible and you have near total control of schedule. I'm also 1099 using wife's federal benefits. My pre-tax income is about 315k working 4 days per week. I chose a job with good lifestyle and my preferred patient population.

There are a lot of trade-offs though. 1) My patient population has high medical co-comorbidities, so get used to patient's dying from seemingly preventable medical causes due to med non-compliance or lack of resources. 2) Reliance on community resources which shift their policies and screw over your patients, seemingly at random. 3) You really have to accept you have no control over any of the actions of your patients, even when they're medicated. 4) Safety concerns associated with going to high risk neighborhoods and seeing actively using or med noncompliant patients. I've had a few uncomfortable situations, but no one on my team has been assaulted. 5) Management usually sucks. 6) Technically I'm always on phone call, but I've had very few calls on the weekends and never overnight. 7)You'll get treatment-resistant patients and sometimes no matter what you do your best won't feel like enough.

 

[Evidence Based]

Popping in to add that I work in an academic CMHC and really love it despite all the hurdles named above. My colleagues are amazing as are the patients, and while we face the same problems with administration, pressure to see more patients, etc, people care enough to stick around to fight to make this place better which gives me a lot of hope. We have a number of excellent subspecialty clinics that are as good if not better than many of the bigger name academic places around here, and I love the ones I work in (psychosis and dual diagnosis).
We're working to get nursing support as above for inbox and phone management as that's one of the biggest headaches right now, and would make this place more attractive to work in.
Given the academic affiliation I also have some research and teaching time which makes for a nice split in my work life, and allows me to have balance while working with the populations I care most about treating.

 

[forchinet121]

My set up is similar to your and I love it. I moonlighted at a few different state-run CMHC's in residency and liked what I saw there, love the underserved population. We don't have a medical clinic and the times for appointments is shorter, but the pay is way higher than the ones that gave more time. I do supervise 4 ARNP's and some ARNP students. After about a year they are well-trained and very independent, but do staff difficult cases with me. We also have a Crisis Unit, 4 week residential substance treatment facility, day treatment for kids, IOP, great nurses and admin support.

Great job supervising 4 NPs and contributing to the downfall of our speciality, excellent work. I’m also glad you think after 1 year they are very independent and that it takes one year of supervision to be an independent psychiatrist, sounds very lovely.

 

[erg923]

Great job supervising 4 NPs and contributing to the downfall of our speciality, excellent work. I’m also glad you think after 1 year they are very independent and that it takes one year of supervision to be an independent psychiatrist, sounds very lovely.

Son, do you know how many times we inquire about if patient has had a relatively recent psychiatric diagnostic/medication evaluation, and all the health plan can find is a handful of psych NPs within 100 miles or so? Fly over states and Medicaid coverage/benefits mostly, by the way.

PCPs are mostly the "mental health professionals" in these situations, mind you. What exactly are you suggesting for these situations? Most of the country is not LA, Marin County, NY, Chicago, etc.

This is a natural consequences of so many psychiatrists opting out of Medicaid. They will see a PCP... and if lucky, a psych NP with MD psychiatrist "oversight." Not sure about the quality of oversight/supervision though. Sometimes a psychiatrist if they are in outpatient MAT for SUDs/dual diagnosis. The ACT teams we have in various states usually have one psychiatrist dedicated for hundreds of patients.

 

[TheRightMedication]

Great job supervising 4 NPs and contributing to the downfall of our speciality, excellent work. I’m also glad you think after 1 year they are very independent and that it takes one year of supervision to be an independent psychiatrist, sounds very lovely.

Part of me supports this rebuke. I am reminded of the counterpoint to that, however -

If not NP's, what is the alternative? How will we meet the demand for services which will outstrip supply more and more?

I know I've said cynical things about public psychiatry above, but my cynicism is no more a solution than is the rejection of the NP idea.

I'm not advocating for NPs, I'm advocating for someone smarter and better constituted than I to think of a better solution.

 

[hallowmann]

I'm out here with you, county run primarily outpatient with SUD, integrated primary care, and homeless outreach responsibilities as well. All SMI, and I see a lot of the same problems.

Biggest issue for us is retention. We hemorrhage therapists, and much of our supply is pre-licensed, so they stay in a de facto internship for 1-2 yrs, and then peace out to greener pastures. I don't blame them because pay is terrible for them, but it basically means they do short-term structured therapy, groups when available, and that's it. We also struggle to keep nursing staff at times, which is rough, but they like some clinics and dislike others because of the culture and streamlining of responsibilities. I'm lucky to be at a place they like most of the week.

Pay is decent, easily competitive with any private employed jobs I applied for and well above academia, and benefits are solid, but vesting for pension takes time. People here are actually pretty nice, motivated, care about what they do, so its been refreshing in that way. Admin and paperwork is at times frustrating, but medical leadership is very supportive for what's best for patients and the docs. Very few NPs/PAs here and I think only the directors do direct supervision for them. We also regularly get residents (Psych and FM) as well as med students (mostly 3rd yrs), which is nice, but slows things down. I feel like teaching could be better for residents, so I'll try and work on that.

There definitely is some mismanagement, but there's a motivated group of relatively recent grads in leadership that are moving the needle and bringing things up to speed in terms of treatment practices though. We have a bimodal distribution of psychiatrists so we are also having to see more in the setting of attrition by retirement. Recruitment isn't as fast as it needs to be (adding physicians every few months but losing twice that to retirement/moves).

There are some archaic policies (e.g. limited remote work/required physical presence in clinics, lots of bureaucratic documentation requirements and a just bad EMR), which is definitely a drag on the day, but patient load is good (1 hr admin daily, 30-45 min returns, 60-90 min evals - depending on complexity) and patients always have a clinical assessment with social work (students mostly and the quality of this varies depending on the individual doing it). That said, its frustrating because it feels like no matter how much time there is its always full with stuff that just feels like inefficiencies in the system.

Some community mental health centers absolutely do home/shelter visits. I worked in a clinic for a couple years in residency that was primarily homeless/low income patients and the psychiatrists/NPs there did home visits with the social workers not infrequently (and as far as I know they weren't part of an ACT team or something, that was separate).

Also props to you OP to doing work that's absolutely under-recognized, under-resourced and often underpaid. It's a rough environment for sure but as you're already finding out being even semi-competent can make a big difference for some of these people that nobody else seems to care much about.

This is normal with ACT and street medicine, and its usually a team going out. It is very rewarding though, meeting people where they're at can give you a lot of insight that's missed when they come to the same clinic every time. SUD is also very prevalent and comorbid in our patients including the ones in ACT, and I'd say that so is some degree of BPD, ASPD gets screened out though.

I think you're correct and that's probably the difference. Most of my patients have PTSD and/or psychosis. The house visits I've made were for various reasons--a young man who had been stabbed and was afraid to leave his house to come into the clinic, another man living in a group home starting to isolate himself and was afraid of the police in front of our clinic, etc. I'm always going out with a case manager or nurse, not alone. Sometimes it's to see for myself someone's living conditions. I also do it to build credibility with the team.

A few times, it's when someone's missed their appointments. An hour of my time going out sometimes gets them to come in and not leave a gap in my schedule as a no show. I think it's because they consider it harassment and would like me to stop going out and invading their space.

I also did home visits while in residency, which might not be common. This was more for seeing patients who were homeless or living in encampments. Most of the time people would not have been seen otherwise, and relationships did build up over time. Patients were sometimes protective of us. We knew when to walk away and just come back another day.

Structured settings such as the ED and inpatient units were where I felt more wary, since there was nowhere for me or the patient to run away to. I was also their obvious target, if I was telling them they couldn't leave or had taken hours to come see them. When any of us feel trapped, that's when violence happens.

Its nice to have that versatility. Are you having home visits interspersed with regular clinic? Sounds like we treat very similar populations.

fairly good pay. Were roughly the same amount in pay terms, but my patient load is very reasonable (30 min f/u, 1 hour intakes), Was seeing 20+ patients a day at community psych job last job. Not even counting supervision duties. I would go crazy with paper charts though. my handwriting is awful, i wouldnt be able to read my notes lol. Most community psych places have sovereign immunity right? my last one did i think. my current job actually has it. That is a nice perk.

Yeah, that sounds terrible. We at least have a bad EMR, which I'll still take over paper notes, and no supervision duties, except one or two 3rd yr residents, and definitely way less patients. The people who are considered "busy" are still only seeing 12-14 a day.

Part of me supports this rebuke. I am reminded of the counterpoint to that, however -

If not NP's, what is the alternative? How will we meet the demand for services which will outstrip supply more and more?

I know I've said cynical things about public psychiatry above, but my cynicism is no more a solution than is the rejection of the NP idea.

I'm not advocating for NPs, I'm advocating for someone smarter and better constituted than I to think of a better solution.

To be completely honest, my take on this is that NPs could work, but there needs to be real supervision, like staff every patient, possibly briefly see a patient, review every note, etc. Evals/news should be handled by psychiatrists as well. I really can't imagine how you can effectively supervise more than 2 NPs with full schedules at a given time when that's all you're doing, let alone 4 with a full schedule yourself as well. I've seen systems that work with real supervision and NPs that are well trained and know when to run important things by the psychiatrist. I've also seen the same train wreck that everyone else sees with unsupervised NPs and PAs that think they have nothing to learn and that everytime there's a complaint it means they need to add a new med.

 

[clausewitz2]

To be completely honest, my take on this is that NPs could work, but there needs to be real supervision, like staff every patient, possibly briefly see a patient, review every note, etc. Evals/news should be handled by psychiatrists as well. I really can't imagine how you can effectively supervise more than 2 NPs with full schedules at a given time when that's all you're doing, let alone 4 with a full schedule yourself as well. I've seen systems that work with real supervision and NPs that are well trained and know when to run important things by the psychiatrist. I've also seen the same train wreck that everyone else sees with unsupervised NPs and PAs that think they have nothing to learn and that everytime there's a complaint it means they need to add a new med.

Not an original observation, but again, this supports the idea that NPs ideally ought to function as senior residents more or less forever.

 

[Candidate2017]

Part of me supports this rebuke. I am reminded of the counterpoint to that, however -

If not NP's, what is the alternative? How will we meet the demand for services which will outstrip supply more and more?

FMs are the stop-gap for every medical issue, from CHF to schizophrenia. They do a relatively decent job compared to midlevels. Unlike midlevels, they know their limits, so they know when/where to look up info or curbside a psychiatrist. Even if there isn't a psychiatrist in their Box shop, just about every FM has the phone number of a psychiatrist in their cell phone, via friendships made in med school/residency, family and/or marriage.

I've also found the typical MS-3 rotating on inpatient psychiatry has more textbook knowledge than NPs and PAs with years of experience, and generally has a WTF response when they read a midlevel's psychotropic plan.

There are a lot of trade-offs though. 1) My patient population has high medical co-comorbidities, so get used to patient's dying from seemingly preventable medical causes due to med non-compliance or lack of resources. 2) Reliance on community resources which shift their policies and screw over your patients, seemingly at random. 3) You really have to accept you have no control over any of the actions of your patients, even when they're medicated. 4) Safety concerns associated with going to high risk neighborhoods and seeing actively using or med noncompliant patients. I've had a few uncomfortable situations, but no one on my team has been assaulted. 5) Management usually sucks. 6) Technically I'm always on phone call, but I've had very few calls on the weekends and never overnight. 7)You'll get treatment-resistant patients and sometimes no matter what you do your best won't feel like enough.

Most of the things you mention are present in any psychiatry environment or medicine in general: self-preventable deaths from med comorbidities, zero control over patients, sucky management, being on call, treatment resistance.

That's 100% why we screen everyone and won't be bullied into taking inappropriate patients.

But the CMHCs I've seen don't usually screen.

The real problem with CMHCs is they lobby state/local governments, and get hundreds of millions of dollars annually, based on the premise they can reduce Medicaid psychiatric costs by managing patients on an outpatient basis, and then turn around and offer psychiatrists and staff very low wages. It's a money generating racket. I can't keep track of all the times consults has seen a patient who tried to commit suicide and has recommended psych hospitalization, but then the CMHC overrides, gives a neg cert, and sends them home ("not actively suicidal"). But hey, money has been saved by preventing a psychiatric hospitalization.

 

[hallowmann]

FMs are the stop-gap for every medical issue, from CHF to schizophrenia. They do a relatively decent job compared to midlevels. Unlike midlevels, they know their limits, so they know when/where to look up info or curbside a psychiatrist. Even if there isn't a psychiatrist in their Box shop, just about every FM has the phone number of a psychiatrist in their cell phone, via friendships made in med school/residency, family and/or marriage.

I've also found the typical MS-3 rotating on inpatient psychiatry has more textbook knowledge than NPs and PAs with years of experience, and generally has a WTF response when they read a midlevel's psychotropic plan.

I really do think people sell FM/primary care short for what they can do. The real problem is that the same people pushing NP autonomy and FPA are the same people expecting FM to see 30+ pts a day with 15 min visits. It makes most primary care physicians feel like they can't adequately treat psychiatric conditions given everything else they need to cover. All part of the degradation of the healthcare system.

The real problem with CMHCs is they lobby state/local governments, and get hundreds of millions of dollars annually, based on the premise they can reduce Medicaid psychiatric costs by managing patients on an outpatient basis, and then turn around and offer psychiatrists and staff very low wages. It's a money generating racket. I can't keep track of all the times consults has seen a patient who tried to commit suicide and has recommended psych hospitalization, but then the CMHC overrides, gives a neg cert, and sends them home ("not actively suicidal"). But hey, money has been saved by preventing a psychiatric hospitalization.

Yeah, honestly I interviewed at some CMHCs in the same region, and they were seriously paying 20-30% less than private places and 30-40% less than where I am now. They were also expecting 20 patients per day as well. It really depends very heavily on the structure, leadership, and people involved.

 

[Coupd'Cat]

Its nice to have that versatility. Are you having home visits interspersed with regular clinic? Sounds like we treat very similar populations.

Yes, I have regular clinic and enough flexibility to choose when I'd like to sprinkle in a home visit for my patients--it isn't required, but I find it fun.

Just to add (for residents/students interested in community psych), not all jobs are 20+ patients in 15 minute slots. My ACT job is like 3-4 patients per day currently. I will probably avg 5 per day once the patient panel is maxed out. Hours are very flexible and you have near total control of schedule. I'm also 1099 using wife's federal benefits. My pre-tax income is about 315k working 4 days per week. I chose a job with good lifestyle and my preferred patient population.

There are a lot of trade-offs though. 1) My patient population has high medical co-comorbidities, so get used to patient's dying from seemingly preventable medical causes due to med non-compliance or lack of resources. 2) Reliance on community resources which shift their policies and screw over your patients, seemingly at random. 3) You really have to accept you have no control over any of the actions of your patients, even when they're medicated. 4) Safety concerns associated with going to high risk neighborhoods and seeing actively using or med noncompliant patients. I've had a few uncomfortable situations, but no one on my team has been assaulted. 5) Management usually sucks. 6) Technically I'm always on phone call, but I've had very few calls on the weekends and never overnight. 7)You'll get treatment-resistant patients and sometimes no matter what you do your best won't feel like enough.

Thanks for reminding me that residents/students still read this forum. Where are you all? What happened to the group program reviews? Are you okay? Back in my day--

Similarly, there is a wide variation among the caseloads within our CMHC. On the far end, one of our psychiatrists sees 10-12 patients a day for 15-30 minute sessions. I see between 4-7 patients a day. I refuse to do 15 minute med checks, for preservation of my soul. I love the total control of my schedule--ditto on that.

Still would highly recommend working at a CMHC to any resident interested in community psychiatry and if options nearby are reasonable, as they appear to vary widely based on posts above.

Having not worked in other settings, I don't know if what appears to be shoddy management and promotion of the least principled among us is unique to the state system or present in the private/academic sector as well. This seems to be nothing new, judging by the former AACP president and founder Gordon Clarke's mini-manifesto and survey of CMHC psychiatrists in the 80s. He argued for giving medical directors more administrative power and appointing more psychiatrists as the CEOs.

Advice I would have for residents entering work at a CMHC, individual results may vary:
1. Try to avoid management as much as you can. Familiarize yourself with the particular brand of human that is "middle management". You can identify them as the person with no real power or clinical experience who appears to mostly audit clinical work and cite policies as to why certain things cannot be done. Most of the time, they have no idea what a psychiatrist does, despite having been a manager for 30 years. Their anxiety can be soothed with brief scheduled check-ins, which will save you the headache of a thousand emails.
2. Check out your union. They often have a wealth of institutional knowledge. It's helpful to know what issues are unique to your clinic vs. endemic to the institution. And what has been attempted to change that, if anything.
3. For the demoralization, my recipe is the motto "I ACCEPT THAT THIS IS HAPPENING" and a supply of stress balls. I broke one the week after I got it. Three are on my desk. I have a box of forty in a cupboard.
4. You will see people put on years of antipsychotics because they got into one fight with a family member when they were 17 and got diagnosed with bipolar disorder. When you ask the previous psychiatrist why they added this diagnosis, they may respond that "that's what we did to justify prescribing a medication". You will see people balloon up and develop fatty liver on these meds. You will see women get diagnosed with psychosis because they flipped out when DCF took away their child. You will see people who were put into foster care and suffered more abuse because DCF decided their mother (usually a woman of color and poor) would be a deficient caretaker and the State would do a better job. Refer to #3. Deprescribe when you can.