Why?

[sunlioness]

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Why when a doctor is leaving in less than a month would you continue to have new patients on their schedule???

It's really grinding my gears. I've gotten nowhere trying to address it.

They say access is bad and patients will get upset being told they have to wait even longer. They're still getting upset. But this way they also get to take it out on me.

 

[VMSmith]

Is someone's bonus tied to wait times? Or maybe clinic funding in some way?

Whenever something makes no sense from a clinical perspective, you have to wonder who benefits (usually financially) from the status quo.

 

[F0nzie]

I know the feeling. I cut back my hours after complaining that I was seeing too many patients yet they are still stacking more lol :x.

 

[Shikima]

Bad administrators. If it's a VA, you can file an anonymous complaint with IG.

 

[sunlioness]

Yeah. It's not.

It's just so frustrating. And now I have to find timely follow up for these people. I'm mostly just throwing them to the NPs, but they're not all patients I would normally deem to be NP appropriate. But I can't start someone on a new med who needs it and tell them it'll be 4 months before they can see somebody.

I send back to primary when I can. But with an initial visit ... Usually not appropriate right away. There are a few who probably could go back to primary. But they need a few more visits first. The NPs will be fine for that.

 

[Shikima]

You could play your hand loudly with the CMHC admin saying if they don't knock this off you'll be looking for a new job......

That's a hard one to play out and depends on your level of tolerance for nonsense.

 

[F0nzie]

You could play your hand loudly with the CMHC admin saying if they don't knock this off you'll be looking for a new job......

That's a hard one to play out and depends on your level of tolerance for nonsense.

TBH I haven't been interested in any of the jobs out there. I have a lot of moonlighting experience and I have worked in various settings and it's all meh. So I am like whatever be a dick to me this sucks anyways. Rotations in med school and residency is probably the most fun I have had in psych.

 

[sunlioness]

I'm still seeing about 6- 8/week. The one this afternoon is chronically mentally ill and coming in because they don't like the CMHC. They have an established psychiatrist, but don't like them. So I have to see them this afternoon and try to figure it all out. Request records, come up with a treatment plan and figure out dispo.

So not happy. This person has a doc and COULD wait several more months.

 

[milesed]

They may be hoping to fill the position before the patients are seen next.

 

[sunlioness]

No, they're not actually. They're hoping to hire a locum, but that hasn't come through yet. Recruitment is ongoing and predates my resignation.

It's just a tough situation for everyone.

 

[heyjack70]

Perhaps if pay was increased physicians wouldn't mind all the work. Or they could actually recruit someone new.

 

[smalltownpsych]

They don't want to understand what we do. They also need to devalue it. People are terrified of mental illness and we get to see some pretty sophisticated defense mechanisms at play when we deal with administrators. Also, they can't admit that they don't know what they are doing, see Kohut's concept of narcissistic defense against feelings of inadequacy. Why do you think they want to relegate psychiatrists to the role of pill pushers and everyone can be a therapist?

 

[Doctor Bagel]

Yeah. It's not.

It's just so frustrating. And now I have to find timely follow up for these people. I'm mostly just throwing them to the NPs, but they're not all patients I would normally deem to be NP appropriate. But I can't start someone on a new med who needs it and tell them it'll be 4 months before they can see somebody.

I send back to primary when I can. But with an initial visit ... Usually not appropriate right away. There are a few who probably could go back to primary. But they need a few more visits first. The NPs will be fine for that.

So they're forcing you to see people you can't follow up with and yet leaving you stuck with finding appropriate follow up? That seems like a bad setup. I had new intakes in my last month of fellowship at the VA, but follow up was their problem not mine.

 

[manly_man246]

Off topic post:

Rotations in med school and residency is probably the most fun I have had in psych.

This sucks for me to read. I've read a lot of your posts in working up to my decision to apply to Psychiatry this summer. Like many of the other MS-4s on this board I've had a hard time making this decision. I love the problems Psychiatrists solve and the drastic differences that can be made, I've had a blast on almost every Psych rotation, which can't be said for many other of my clinical experiences, but I've just had a lot of doubt for the usual reasons people on here cite. And because I am in AOA territory at my top-15 medical school and I scored above the 90th-%ile on Step 1 and Step 2 there are a lot of doors open to me. Reading posts from f0nzie and sunlioness and shikima and countless people I'm forgetting stretching back years helped convince me that if I'm happiest and having the most fun when on my Psych rotations, think I'll really make a difference for my patients and can make a great psychiatrist, and enjoy the lifestyle so much I should do it because it's still rewarding and enjoyable after training. So reading this isolated quote (which is probably made in reference to the paperwork/socialwork/office-life bull**** that any physician will face when there aren't residents in the way to take care of it) worries me a lot and makes me question if giving up whatever it is that I'm giving up by choosing Psych over something else (money, most likely) is worth it.

I hope people don't see this and jump on it as me being insecure in my decision or whatever - I've ruled out most other things (except ENT, Anesthesia, and palliative) and most of them I don't have the letters/research to get in to even w/ my "stats." Just freaking out as I get closer and closer to the submission deadline given that my friends and mentors tell me I "still have time" if I want to make a switch.

 

[Psychotic]

I hope people don't see this and jump on it as me being insecure in my decision or whatever - I've ruled out most other things (except ENT, Anesthesia, and palliative) and most of them I don't have the letters/research to get in to even w/ my "stats." Just freaking out as I get closer and closer to the submission deadline given that my friends and mentors tell me I "still have time" if I want to make a switch.

Who is telling you still have time to switch? You have to line up letters for ERAS, including letters from department heads, etc., and that takes a lot of time, forethought, and planning. I remember having lined up all letters by this date (at least formal requests were put in, and I had provided a ready-to-go personal statement to review, too, as well as scheduled and attended interview/meetings with letter writers) a couple of years ago, and I can't imagine "switching" at this late date for that reason alone.

I am not jumping on you, but dude, you are floundering here. Also, you can get to palliative via psych, FWIW. But if you are still heavily weighing ENT, or even anesthesia, vs psych, I swear you are lost in the woods. You are all over the map and should have gotten your bearings well before late July. Stop reading comments here and go on a personal retreat if necessary to get your head straight.

 

[manly_man246]

^I have letters from department heads and others already for my primary backup choice. I could always jump ship and choose to apply to categorical medicine but it and the subspecialties don't interest me nearly as much as Psych

 

[Doctor Bagel]

^I have letters from department heads and others already for my primary backup choice. I could always jump ship and choose to apply to categorical medicine but it and the subspecialties don't interest me nearly as much as Psych

Do you like working with psych patients? I'm still new to this (just finishing fellowship), but it seems like that's a key factor for continuing to like this field. Most doctors don't, which is why they don't do what we do and would probably be miserable in spite of our more friendly work/life balance.

Also, in your post above, you mentioned "drastic changes." True, they can happen, but psychiatry is one of those chronic care types of specialities where drastic changes happen with some patients, but for lots of our patients, small changes or just maintaining are closer to their reality. Treatments that we have so far for severe mental illnesses are severely lacking, and that can be disheartening if you're really looking for those drastic improvements.

I started my residency with someone who was very undecided about psych and was thinking about surgical specialties beforehand. She wound up transferring to internal medicine and was much happier. Lots of people wind up transferring from fields like anesthesia and surgery to psych, though, and are happier here. So, rambling, but I guess the good news is that whatever you decide, you can switch fields if it's really not right. ENT and anesthesia do sound very different from psych, though, so I am wondering what the appeal of psych is. Just liking the people you work with in psychiatry isn't enough.

 

[manly_man246]

Do you like working with psych patients? I love it, I love working on the problems they have (vs DM, CHF, COPD, pancreatitis, ACS ruleouts, etc). I have done outpatient, inpatient, acute care, C/L, and private rotations, I know the different settings I could work in and got experience with pain, eating disorders, sleep, forensics, and ECT. I could see myself doing any or all of them during my career at various points . I'm still new to this (just finishing fellowship), but it seems like that's a key factor for continuing to like this field. Most doctors don't, which is why they don't do what we do and would probably be miserable in spite of our more friendly work/life balance.

Also, in your post above, you mentioned "drastic changes." True, they can happen, but psychiatry is one of those chronic care types of specialities where drastic changes happen with some patients, but for lots of our patients, small changes or just maintaining are closer to their reality. Fine with me, the relationships can be rewarding, some patients are frustrating and it's just an agonizing 15-30 minutes but that's true everywhere. Treatments that we have so far for severe mental illnesses are severely lacking, and that can be disheartening if you're really looking for those drastic improvements.

I started my residency with someone who was very undecided about psych and was thinking about surgical specialties beforehand. She wound up transferring to internal medicine and was much happier. Lots of people wind up transferring from fields like anesthesia and surgery to psych, though, and are happier here. So, rambling, but I guess the good news is that whatever you decide, you can switch fields if it's really not right. ENT and anesthesia do sound very different from psych, Yeah my backup is ENT as I just liked anesthesia intellectually, but hated not talking to my patientsthough, so I am wondering what the appeal of psych is. Just liking the people you work with in psychiatry isn't enough.

 

[F0nzie]

Manly man I popped on this thread to vent. Psychiatry is #1.

 

[PikminOC]

Is someone's bonus tied to wait times? Or maybe clinic funding in some way?

Whenever something makes no sense from a clinical perspective, you have to wonder who benefits (usually financially) from the status quo.

Yes. Admins think very differently from us. Heads roll there regularly.

 

[PikminOC]

So they're forcing you to see people you can't follow up with and yet leaving you stuck with finding appropriate follow up? That seems like a bad setup. I had new intakes in my last month of fellowship at the VA, but follow up was their problem not mine.

Admins don't care at all about the doctor. The liability is not their prob...

 

[PikminOC]

They don't want to understand what we do. They also need to devalue it. People are terrified of mental illness and we get to see some pretty sophisticated defense mechanisms at play when we deal with administrators. Also, they can't admit that they don't know what they are doing, see Kohut's concept of narcissistic defense against feelings of inadequacy. Why do you think they want to relegate psychiatrists to the role of pill pushers and everyone can be a therapist?

Admins are all about numbers. They have pressure from above. They aren't discriminatory. They treat all fields like this.
Crunch numbers...Its all about volume and coding...
How else can they get paid?

 

[smalltownpsych]

Admins are all about numbers. They have pressure from above. They aren't discriminatory. They treat all fields like this.
Crunch numbers...Its all about volume and coding...
How else can they get paid?

True that it is about the numbers but it is not only about the numbers. The well-put together corporate suit types feel really uncomfortable with what we do and the type of patients we see. Of course, many people feel that way, including docs from other specialties. At least The other docs are pretty open that they don't like dealing with our patients. The suits feel that they have to pretend like they care. They struggle a bit more with that ambivalence than we do. After all ambivalent feelings is where we live as Fonzie so aptly demonstrated above.

 

[sunlioness]

I love palliative too. Very rewarding. I don't do it, but I've thought about doing it. And you can get there from psychiatry, which is nice. Just when I looked into it it seemed that psych wasn't the most respected pathway to get there and you probably end up making less money than you would as a general psychiatrist. Didn't seem like a compelling enough reason to do a fellowship. But I did really like it.

I like psychiatry. I really do. I think I may come off as jaded a lot. But I like the patients. I like the work. I don't like the BS that is so often a part of being in medicine. But you're going to have that in every field. And in many fields it's way worse. (I don't know how my friends who are ED docs do it. I really don't).

 

[clausewitz2]

I love palliative too. Very rewarding. I don't do it, but I've thought about doing it. And you can get there from psychiatry, which is nice. Just when I looked into it it seemed that psych wasn't the most respected pathway to get there and you probably end up making less money than you would as a general psychiatrist. Didn't seem like a compelling enough reason to do a fellowship. But I did really like it.

Two weeks of palliative was my favorite bit of my IM rotation by a country mile (ID a distant second). When I asked my preceptor, an old palliative hand who directs hospice for our local VA facilities, why he thought there weren't more psychiatrists in palliative since they could sit the board, his response was "Can they?" He had literally never met one.

 

[splik]

Two weeks of palliative was my favorite bit of my IM rotation by a country mile (ID a distant second). When I asked my preceptor, an old palliative hand who directs hospice for our local VA facilities, why he thought there weren't more psychiatrists in palliative since they could sit the board, his response was "Can they?" He had literally never met one.

its not wildly uncommon for psychiatrists to do palliative medicine. remember the fellowship is fairly recent develop in the US as palliative medicine is only really just taking off here, so most palliative medicine docs are not fellowship trained, much less boarded. where I am one of the psychiatrists attends on the palliative care service and its one of the "palliative care centers of excellence" whatever that means. she'd never have been able to get away with being non-trained or boarded going in today but even a few years ago this was possible. remember they are both symptom focussed specialties which provided services that nobody wants to pay for! and delirium, depression, demoralization, anxiety, agitation are some of the most common palliative care problems.

outside of large (typically academic) institutions it is not really possible to make any money doing palliative medicine (and of course no one makes any money doing it in academia either but it's funded through private endowments, grants, and the fact it is in concert or 2nd to OB/GYN typically the service with the highest patient satisfaction). an example: the institute of palliative medicine/San Diego Hospice which provided fantastic care collapsed a couple of years ago because they were providing such fantastic care. They also ran the first palliative psychiatry fellowship in the country which was headed by scott irwin who incidentally did not have an HPM fellowship nor board certification in HPM.

it is one of those specialties where you can expect to take a pay cut.

 

[SmallBird]

its not wildly uncommon for psychiatrists to do palliative medicine. remember the fellowship is fairly recent develop in the US as palliative medicine is only really just taking off here, so most palliative medicine docs are not fellowship trained, much less boarded. where I am one of the psychiatrists attends on the palliative care service and its one of the "palliative care centers of excellence" whatever that means. she'd never have been able to get away with being non-trained or boarded going in today but even a few years ago this was possible. remember they are both symptom focussed specialties which provided services that nobody wants to pay for! and delirium, depression, demoralization, anxiety, agitation are some of the most common palliative care problems.

outside of large (typically academic) institutions it is not really possible to make any money doing palliative medicine (and of course no one makes any money doing it in academia either but it's funded through private endowments, grants, and the fact it is in concert or 2nd to OB/GYN typically the service with the highest patient satisfaction). an example: the institute of palliative medicine/San Diego Hospice which provided fantastic care collapsed a couple of years ago because they were providing such fantastic care. They also ran the first palliative psychiatry fellowship in the country which was headed by scott irwin who incidentally did not have an HPM fellowship nor board certification in HPM.

it is one of those specialties where you can expect to take a pay cut.

Thats really interesting. Do you think it could be demonstrated that palliative care services can reduce costs to hospitals? I remember many occasions where the service would help families make good decisions about withdrawal of care where otherwise an additional $1 milllion might have been spent on an extra three weeks of discomfort in the ICU. Of course even if this could be demonstrated that would be less than half of the challenge of getting the services reimbursed.

 

[Psychotic]

outside of large (typically academic) institutions it is not really possible to make any money doing palliative medicine (and of course no one makes any money doing it in academia either but it's funded through private endowments, grants, and the fact it is in concert or 2nd to OB/GYN typically the service with the highest patient satisfaction). an example: the institute of palliative medicine/San Diego Hospice which provided fantastic care collapsed a couple of years ago because they were providing such fantastic care. They also ran the first palliative psychiatry fellowship in the country which was headed by scott irwin who incidentally did not have an HPM fellowship nor board certification in HPM.

it is one of those specialties where you can expect to take a pay cut.

Is this fellowship still a going concern? I had read about it a few years ago and it caught my attention, but just curious if the program is still ongoing if the parent program collapsed?

 

[st2205]

Thats really interesting. Do you think it could be demonstrated that palliative care services can reduce costs to hospitals? I remember many occasions where the service would help families make good decisions about withdrawal of care where otherwise an additional $1 milllion might have been spent on an extra three weeks of discomfort in the ICU. Of course even if this could be demonstrated that would be less than half of the challenge of getting the services reimbursed.

I would presume the largest benefits (financial) are quite indirect and come from good word-of-mouth and community relations as people will remember the care of their dying loved-one more than other things.

 

[Therapist4Chnge]

I'm still seeing about 6- 8/week. The one this afternoon is chronically mentally ill and coming in because they don't like the CMHC. They have an established psychiatrist, but don't like them. So I have to see them this afternoon and try to figure it all out. Request records, come up with a treatment plan and figure out dispo.

So not happy. This person has a doc and COULD wait several more months.

What a frustrating experience.

The lack of records drives me nuts bc it is never the healthy pt and invariably there is some kind of rush on top of it. I book out far enough I almost always get records, but often not all of them....unless it is the VA, which takes 3 phone calls and a month to get.

 

[manly_man246]

There are direct financial benefits and the research in this area is steadily increasing. Benefits are numerous, patient and family get more meaningful and functional time together, hospital saves a boatload potentially, and Healthcare providers are reduced of the guilt, stress, and burnout of charts treating patients who would be better off w comfort care with daily blood, lytes, and abx. I've been in that situation, and it's awful for the team. My resident had cared for that particular pt for several months off and on, and the decision to move to comfort care was cathartic and healing for everyone.