Another I’m getting close to burnout post

[lockian]

I realized I feel morally injured that I don’t feel like I have adequate tools to help my patients and the patients also impede my efforts a substantial part of the time. Someone told me that if you focus on acknowledging those people who do improve and try to make a goal of seeing people improve just 10%, that’s going to make success feel much more attainable… Are there other strategies that people have found helpful?

Also I wanted to help my practice partners by taking on more new patients and for the last few months I’ve been doing 3 new patients daily plus up to 10 old ones daily and managing my otherwise chaotic panel’s phone calls/messages. That’s too much, isn’t it? (The crazy number of intakes ends this month however, which can’t come soon enough).

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[Ironspy]

3 new patients a day regularly is too many. I’ve done this a few times and it’s not sustainable. 8-12 patients with 1 or fewer new patients a day. I also limit what I am willing to manage by phone. Med changes, new symptoms, new side effects need to be evaluated

 

[lockian]

3 new patients a day regularly is too many. I’ve done this a few times and it’s not sustainable. 8-12 patients with 1 or fewer new patients a day. I also limit what I am willing to manage by phone. Med changes, new symptoms, new side effects need to be evaluated

Yeah, lesson learned. I’m not doing this again. I’m still early career so I guess I did not know what is normal. Thankfully I have great nurses to help out.

 

[Sushirolls]

You have run the gauntlet. You have a license, residency certificate, and probably board certification.

You define what's normal. If your bosses or colleagues disagree, leave and go open your own practice and make it normal.

No one is going to fix your burn out for you. Larger health systems will pay lip service to burn out and say do our wellness program. At best they will get you a scribe and pay you much less for this service. They have no solutions, and aren't vested in solutions, when they can continue to churn through ARNPs and PAs.

Ultimately, you have to find your own burnout solution. The Big Box shops won't change and won't reduce their bureaucracy. The insurance companies ditto. The government ditto.

I improved my life by opening a private practice and I am the CEO/Manager/etc.

 

[PikminOC]

You have run the gauntlet. You have a license, residency certificate, and probably board certification.

You define what's normal. If your bosses or colleagues disagree, leave and go open your own practice and make it normal.

No one is going to fix your burn out for you. Larger health systems will pay lip service to burn out and say do our wellness program. At best they will get you a scribe and pay you much less for this service. They have no solutions, and aren't vested in solutions, when they can continue to churn through ARNPs and PAs.

Ultimately, you have to find your own burnout solution. The Big Box shops won't change and won't reduce their bureaucracy. The insurance companies ditto. The government ditto.

I improved my life by opening a private practice and I am the CEO/Manager/etc.

Weren't you looking recently to go back to employment?

 

[Monocles]

Also I wanted to help my practice partners by taking on more new patients and for the last few months I’ve been doing 3 new patients daily plus up to 10 old ones daily and managing my otherwise chaotic panel’s phone calls/messages. That’s too much, isn’t it? (The crazy number of intakes ends this month however, which can’t come soon enough).

There's your problem.

Are you able to cut back 20-25% of what you are doing now?

 

[Sushirolls]

Weren't you looking recently to go back to employment?

I did consider it, but opted not to. Past burnout from Big Box shops weighed heavily on the pros/cons list and the day to day experience of Big Box Shops. Better off solo PP.

 

[lockian]

There's your problem.

Are you able to cut back 20-25% of what you are doing now?

Yeah, of course I can cut back, and that’s the plan. I know I got myself into this, and even though I work for a big box no one made me do this. I actually have control over my schedule and in this case I happened to take on too much.

Just need to get through the next week since I already committed to that. It’s not a good look when patients have been scheduled for months and they get cancelled short notice.

 

[Sushirolls]

A one week until schedule change can be implemented is a great turn around.

 

[lockian]

A one week until schedule change can be implemented is a great turn around.

Well, to be fair, the plan to do 3 news a day was only meant to last so long. Next month it will be 2 news a day and the month after that 1 new a day.

 

[the5thelement]

Do you have a personal life with active, vibrant connections with other people and energy-producing activities?
This is a helpful read : Burnout: A Primer Carlat Reports | Carlat Publishing

 

[Monocles]

Yeah, of course I can cut back, and that’s the plan. I know I got myself into this, and even though I work for a big box no one made me do this. I actually have control over my schedule and in this case I happened to take on too much.

!! This is actually really great because it shows you are not powerless and have terrible things "happen" to you, as dictated from above.

Let us know how much happier you are in a few months!

 

[lockian]

Do you have a personal life with active, vibrant connections with other people and energy-producing activities?
This is a helpful read : Burnout: A Primer Carlat Reports | Carlat Publishing

It seems to be behind a pay wall.

I guess with the personal life it’s a Catch 22. When you’re exhausted from your job it’s hard to get the ball rolling on those things, so I gave them but I go in cycles of engaging with them.

 

[lockian]

!! This is actually really great because it shows you are not powerless and have terrible things "happen" to you, as dictated from above.

Let us know how much happier you are in a few months!

I still have the other thing where I feel like I can’t actually help my patients, because of therapy interfering behaviors, or because the meds simply have limitations, or myriad other reasons. That’s always there, just gets to me to varying degrees at various times.

 

[Candidate2017]

I realized I feel morally injured that I don’t feel like I have adequate tools to help my patients and the patients also impede my efforts a substantial part of the time.

Maybe you should've done surgery. You use helpful tools, get instant ego gratification, not much cooperation required from the patient besides taking abx and keeping sutures clean, discharge back to their doctor and therapist, and on to the next.

What you describe is par for medicine (i.e., any non-surgical specialty that treats chronic diseases, whether DM, CKD, HTN, CVD, MDD, SUD, personality disorders, etc):

Patient has a disease partly or mostly caused by lifestyle. Doctor recommends lifestyle modifications/non-drug therapies and meds. Patient is only interested in meds. The meds help somewhat in that they blunt the disease process into a slow, controlled decline.

The patient continues to decline non-drug therapies and continues their maladaptive lifestyle that may exacerbate the disease process, necessitating increases in dosages from time to time, and/or addition of more powerful meds with stronger side effects. This continues for decades if all goes well, until the patient dies, whether from the disease, complications, and/or other comorbidities.

Some patients are willing to incorporate lifestyle changes/non-drug therapies with meds, and their disease remits. That's also great.

 

[lockian]

Maybe you should've done surgery. You use helpful tools, get instant ego gratification, not much cooperation required from the patient besides taking abx and keeping sutures clean, discharge back to their doctor and therapist, and on to the next.

What you describe is par for medicine (i.e., any non-surgical specialty that treats chronic diseases, whether DM, CKD, HTN, CVD, MDD, SUD, personality disorders, etc):

Patient has a disease partly or mostly caused by lifestyle. Doctor recommends lifestyle modifications/non-drug therapies and meds. Patient is only interested in meds. The meds help somewhat in that they blunt the disease process into a slow, controlled decline.

The patient continues to decline non-drug therapies and continues their maladaptive lifestyle that may exacerbate the disease process, necessitating increases in dosages from time to time, and/or addition of more powerful meds with stronger side effects. This continues for decades if all goes well, until the patient dies, whether from the disease, complications, and/or other comorbidities.

Some patients are willing to incorporate lifestyle changes/non-drug therapies with meds, and their disease remits. That's also great.

Yeah, maybe I should’ve gone into surgery. I thought the lifestyle was not something I could handle. But when your tougher patients live rent free in your head that makes for a bad lifestyle as well, lol.

 

[Bartelby]

Also I wanted to help my practice partners by taking on more new patients and for the last few months I’ve been doing 3 new patients daily plus up to 10 old ones daily and managing my otherwise chaotic panel’s phone calls/messages. That’s too much, isn’t it? (The crazy number of intakes ends this month however, which can’t come soon enough).

In a productivity-based system I'm not sure why people do this to themselves. I get it in a Kaiser-style system where the goal is to serve a set number of people, but if you are in a productivity-based system this approach does not make sense.

You already have up to 5 hours of follow ups. If those are 30-minute E&M plus therapy slots, that is quite a bit. The three intakes probably take at least 1.5 hours of work (chart review, evaluation, any orders or care coordination, and charting). Under the old RVU system I'm most familiar with that yields about 3.8 RVUs for 1.5 hours of work. A follow-up (30 mins) is 3 RVUs for 30 minutes of work.

The strategy that makes the most sense from almost every angle is to see new patients for frequent follow-up. I often start out with weekly 30-minutes sessions. New patients are often the least stable and appreciate this level of attention. You can actually have time to do CBT-i, brief CBT or supportive therapy, behavioral activation work, etc. etc. You also see them frequently so that out-of-session contact (calls, messages etc) can be minimized. Because you see them so often, it's typically easy to fit all needed work into the 30-minute block.

In contrast, if you flood your nearly-full panel with lots of intakes you will often need to space out follow-ups more. That makes more room for intakes (which reimburse lower) while simultaneously limiting your follow-up slots and making managing those more acute patients harder. It is an all around losing proposition. The only real benefit is access for new patients, but honestly you can't help everyone. If you focus on high quality care for your existing panel (which you gradually expand) the job becomes a lot easier and more fulfilling. At least I imagine it does, I have never agreed to do anything like 3 new outpatient intakes every day.

 

[lockian]

In a productivity-based system I'm not sure why people do this to themselves. I get it in a Kaiser-style system where the goal is to serve a set number of people, but if you are in a productivity-based system this approach does not make sense.

You already have up to 5 hours of follow ups. If those are 30-minute E&M plus therapy slots, that is quite a bit. The three intakes probably take at least 1.5 hours of work (chart review, evaluation, any orders or care coordination, and charting). Under the old RVU system I'm most familiar with that yields about 3.8 RVUs for 1.5 hours of work. A follow-up (30 mins) is 3 RVUs for 30 minutes of work.

The strategy that makes the most sense from almost every angle is to see new patients for frequent follow-up. I often start out with weekly 30-minutes sessions. New patients are often the least stable and appreciate this level of attention. You can actually have time to do CBT-i, brief CBT or supportive therapy, behavioral activation work, etc. etc. You also see them frequently so that out-of-session contact (calls, messages etc) can be minimized. Because you see them so often, it's typically easy to fit all needed work into the 30-minute block.

In contrast, if you flood your nearly-full panel with lots of intakes you will often need to space out follow-ups more. That makes more room for intakes (which reimburse lower) while simultaneously limiting your follow-up slots and making managing those more acute patients harder. It is an all around losing proposition. The only real benefit is access for new patients, but honestly you can't help everyone. If you focus on high quality care for your existing panel (which you gradually expand) the job becomes a lot easier and more fulfilling. At least I imagine it does, I have never agreed to do anything like 3 new outpatient intakes every day.

Yeah, totally agree, and I want to work towards what you just described with frequent follow up. I think I did what I did because I wasn’t thinking things through. I looked two months into the future and saw a lot of empty space and panicked that my schedule would not be filling, and I would be idling.

 

[Bartelby]

I've done some idling starting new jobs, it's a bit anxiety provoking but can be kind of nice too . Bottom line is if I had three new patients and 10 follow ups on a regular basis I'm pretty confident I would burn out quickly too.

Good luck slowing the intakes! Maybe see if you can drop to one per day ASAP.

 

[smalltownpsych]

I still have the other thing where I feel like I can’t actually help my patients, because of therapy interfering behaviors, or because the meds simply have limitations, or myriad other reasons. That’s always there, just gets to me to varying degrees at various times.

This is the hardest part for me too. I can work my tail off when it feels productive. The trick is how to maximize “good” patients and eliminate the “bad” patients. Some of that is determined by who I am most effective with more than their qualities. I work well with Borderline PD so am more comfortable with a heavier load of those than others would, for example. Having intakes are good for determining that and then if it seems like someone in your wheelhouse, as you determine that, then the more frequent follow-ups. Boundaries are also huge. I am nice and approachable by nature, good for rapport, but people could see me as the easy path to get what they want. Learning to politely say no and not get caught in the need for justification helps tremendously. Pet letters is actually a good way for me to practice that skill. I get about one request a month for that. I imagine a psychiatrist probably gets the chance to say no to something at least weekly if not daily.
One more thing, a good mental health provider struggles with burnout because it is also called compassion fatigue. Compassion is a necessary element of our field and the fact that not helping bothers you is actually a sign that you might be in the right specialty.

 

[randomdoc1]

I did consider it, but opted not to. Past burnout from Big Box shops weighed heavily on the pros/cons list and the day to day experience of Big Box Shops. Better off solo PP.

Yea, PP is so a different ball game. Only pre-req to do well and you better have it or you sink, is organization, financial management. Stay ahead on that accounting or patients will stiff you to the bone. I now see my career is a career. Yes, it was for altruistic reasons we pursued it, but it's helped me to view it in the sense that you are only capable of being as helpful as others will let you. Take your job seriously, do your best out of principle, but don't over internalize. And patients not following through on change including being financially respectful to you, is a symptom in my book of ambivalence to change. Well, plenty of people who are more ready. And time for the next person in line. You can't do that at most establishments other than PP, hence the chaos ensues.

With providers here who struggled with this delicate boundary (and I can start seeing the emotional stress they are carrying), I'd tell them my blood bank story. As a medical student, I rotated at a small town hospital. One day, a man came in, esophageal varices. Nearly died. Had many PRBCs (just about the entire bank) but we helped him. However, shortly after, he was back. Then again. And again. And then some more. Same reason, frequency was about once a month. He had no interest in sobriety. This left the hospital at an ethical dilemma, because it's not fair to give all the PRBCs to this patient. We are a form of PRBCs--those PRBCs need to be available to those who will use it well and the PRBCs need to be in good condition--that is us. I bear no guilt. I take my career seriously, but I have a life too. On a lighter note, I bet he never paid his medical bills LOL.

PP also gave me an experience from the upper management side. @Sushirolls it's so different when there are employees. You're fortunate you don't have to deal with it as much. One, employees for the desk and two, providers as employees. Managing different personalities is tough. Think having a borderline as a patient is hard? Try having one as an employee LOL. So I try to be fair to all sides of the argument. But when a provider is making top 5%-ile fair market value when they are just out of school (with an incredible patient population mind you and beautiful office) and is asking for a raise not even a year out and have a disgruntled attitude, it makes me wanna slap someone. Tends to happen in situations when it is their first job here because they have not tasted the general market.

 

[smalltownpsych]

Yea, PP is so a different ball game. Only pre-req to do well and you better have it or you sink, is organization, financial management. Stay ahead on that accounting or patients will stiff you to the bone. I now see my career is a career. Yes, it was for altruistic reasons we pursued it, but it's helped me to view it in the sense that you are only capable of being as helpful as others will let you. Take your job seriously, do your best out of principle, but don't over internalize. And patients not following through on change including being financially respectful to you, is a symptom in my book of ambivalence to change. Well, plenty of people who are more ready. And time for the next person in line. You can't do that at most establishments other than PP, hence the chaos ensues.

With providers here who struggled with this delicate boundary (and I can start seeing the emotional stress they are carrying), I'd tell them my blood bank story. As a medical student, I rotated at a small town hospital. One day, a man came in, esophageal varices. Nearly died. Had many PRBCs (just about the entire bank) but we helped him. However, shortly after, he was back. Then again. And again. And then some more. Same reason, frequency was about once a month. He had no interest in sobriety. This left the hospital at an ethical dilemma, because it's not fair to give all the PRBCs to this patient. We are a form of PRBCs--those PRBCs need to be available to those who will use it well and the PRBCs need to be in good condition--that is us. I bear no guilt. I take my career seriously, but I have a life too. On a lighter note, I bet he never paid his medical bills LOL.

PP also gave me an experience from the upper management side. @Sushirolls it's so different when there are employees. You're fortunate you don't have to deal with it as much. One, employees for the desk and two, providers as employees. Managing different personalities is tough. Think having a borderline as a patient is hard? Try having one as an employee LOL. So I try to be fair to all sides of the argument. But when a provider is making top 5%-ile fair market value when they are just out of school (with an incredible patient population mind you and beautiful office) and is asking for a raise not even a year out and have a disgruntled attitude, it makes me wanna slap someone. Tends to happen in situations when it is their first job here because they have not tasted the general market.

Many of the employees think that somehow it is up to the business to shield them from the difficult patients and dont take ownership of how often they are creating their own problems. Recent employee spent more time and energy trying to help patients who didn’t want it than the ones who did. It was almost like they were replicating the pattern of their own childhood. I guess they don’t teach about managing and addressing countertransference anymore, Regardless of the emotional toll, the financial toll was dramatic. Spinning your wheels and getting frustrated with no shows and non-compliant patients doesn’t pay anything at all. Patients that are improving and have some commitment to the process is where the money is at. Strategies to improve the ability to identify where patients are at in this process are key. I am often very intentional and explicit about the opportunity to demonstrate their willingness. Not only does this weed out the unwilling but it also improves commitment of the ones who are moving through the continuum of change because they are an active partner.

 

[Candidate2017]

Many of the employees think that somehow it is up to the business to shield them from the difficult patients and dont take ownership of how often they are creating their own problems.

Large, insurance-based owners and organizations make money from volume. There's a huge financial incentive for them to accept all patients with decent paying payors, and dump them on the employed psychiatrist and let them deal with it. After all, if something goes wrong, patients can't blame a corporation or owner. But they can blame the psychiatrist.

Psychiatry is not like other specialties. A panel full of alcohol and substance abusers or otherwise noncompliant population, tends to not make many demands of their cardiologist. In fact, such a panel makes their cardiologist a millionaire every 1.5 years or so. The same cannot be said for psychiatry.

 

[smalltownpsych]

Large, insurance-based owners and organizations make money from volume. There's a huge financial incentive for them to accept all patients with decent paying payors, and dump them on the employed psychiatrist and let them deal with it. After all, if something goes wrong, patients can't blame a corporation or owner. But they can blame the psychiatrist.

Psychiatry is not like other specialties. A panel full of alcohol and substance abusers or otherwise noncompliant population, tends to not make many demands of their cardiologist. In fact, such a panel makes their cardiologist a millionaire every 1.5 years or so. The same cannot be said for psychiatry.

What I see is that a lot of people seem drawn to these larger organizations perhaps because they want someone to blame for their crummy work environment, but when given a chance to manage it themselves, do a poor job of it and still look for someone to blame.

 

[lockian]

Yea, PP is so a different ball game. Only pre-req to do well and you better have it or you sink, is organization, financial management. Stay ahead on that accounting or patients will stiff you to the bone. I now see my career is a career. Yes, it was for altruistic reasons we pursued it, but it's helped me to view it in the sense that you are only capable of being as helpful as others will let you. Take your job seriously, do your best out of principle, but don't over internalize. And patients not following through on change including being financially respectful to you, is a symptom in my book of ambivalence to change. Well, plenty of people who are more ready. And time for the next person in line. You can't do that at most establishments other than PP, hence the chaos ensues.

With providers here who struggled with this delicate boundary (and I can start seeing the emotional stress they are carrying), I'd tell them my blood bank story. As a medical student, I rotated at a small town hospital. One day, a man came in, esophageal varices. Nearly died. Had many PRBCs (just about the entire bank) but we helped him. However, shortly after, he was back. Then again. And again. And then some more. Same reason, frequency was about once a month. He had no interest in sobriety. This left the hospital at an ethical dilemma, because it's not fair to give all the PRBCs to this patient. We are a form of PRBCs--those PRBCs need to be available to those who will use it well and the PRBCs need to be in good condition--that is us. I bear no guilt. I take my career seriously, but I have a life too. On a lighter note, I bet he never paid his medical bills LOL.

PP also gave me an experience from the upper management side. @Sushirolls it's so different when there are employees. You're fortunate you don't have to deal with it as much. One, employees for the desk and two, providers as employees. Managing different personalities is tough. Think having a borderline as a patient is hard? Try having one as an employee LOL. So I try to be fair to all sides of the argument. But when a provider is making top 5%-ile fair market value when they are just out of school (with an incredible patient population mind you and beautiful office) and is asking for a raise not even a year out and have a disgruntled attitude, it makes me wanna slap someone. Tends to happen in situations when it is their first job here because they have not tasted the general market.

I have considered PP and the deterrent is oddly enough something that has not yet been mentioned. I don’t feel comfortable without Epic or some system where I can have access to the patient’s full medical history, primary care and other specialty notes, labs, an accurate med list and the ability to message their pcp/other docs at the click of a button. If I don’t have the above I feel like I lack the necessary info or need to rely on ancient systems like fax/phone (with clunky ROIs as a prerequisite to use them) and the patient’s own knowledge and conscientiousness (which may be flawed) to understand their medical history. And psychiatry patients are medical patients. Every med we give them affects their entire body. Has anyone come up with an efficient way to address the above?

 

[Sushirolls]

I have considered PP and the deterrent is oddly enough something that has not yet been mentioned. I don’t feel comfortable without Epic or some system where I can have access to the patient’s full medical history, primary care and other specialty notes, labs, an accurate med list and the ability to message their pcp/other docs at the click of a button. If I don’t have the above I feel like I lack the necessary info or need to rely on ancient systems like fax/phone (with clunky ROIs as a prerequisite to use them) and the patient’s own knowledge and conscientiousness (which may be flawed) to understand their medical history. And psychiatry patients are medical patients. Every med we give them affects their entire body. Has anyone come up with an efficient way to address the above?

I got over the angst in less than 3 months.
1) patients report their history
2) you get records or have the patient get records
3) fax/call/mail/message their specialists your notes or request their notes when really needed

You'll find that Epic level EMR type communication isn't needed as much. I've had 2-3 patients I've specifically referred to a Big Box shop entity because their care was more complex and their specialists should be more in the loop. This is rare.

 

[lockian]

I got over the angst in less than 3 months.
1) patients report their history
2) you get records or have the patient get records
3) fax/call/mail/message their specialists your notes or request their notes when really needed

You'll find that Epic level EMR type communication isn't needed as much. I've had 2-3 patients I've specifically referred to a Big Box shop entity because their care was more complex and their specialists should be more in the loop. This is rare.

Do you get record updates every time you see them? I don’t trust patients to accurately report (low functioning, memory problems, straight up want to hide things).

 

[calvnandhobbs68]

Do you get record updates every time you see them? I don’t trust patients to accurately report (low functioning, memory problems, straight up want to hide things).

Um no. I can count on both hands the number of times I've actually talked to or gotten records from a patient's PCP unless I'm transferring care back to them.

You're not liable for patients lying to you or omitting information. Document that you've reviewed the patient's medical history with them and updated medication list and you're fine. If they don't remember stuff or don't tell you stuff, that's on them, not you, you're not their mom who needs to keep track of their entire medical history.

You think pulm or derm or cardiology hunts down a patient's PCP to get an update on all their other conditions every time they prescribe a med? Hilarious. I mean that's a noble goal but you're gonna burn yourself out really quick spending another 4 hours a day for 8 hours of patients trying to hunt down PCP offices and exchange info.

 

[Sushirolls]

Do you get record updates every time you see them? I don’t trust patients to accurately report (low functioning, memory problems, straight up want to hide things).

For those patients, you document what you did. Do the best you can and move on.
state you faxed your note to PCP, and if really paranoid save the fax confirmation to the chart.
Same thing for requested records from PCP or specialist.

You make the best professional decisions you can with the information you have.

I like my luminello EMR far more than I miss being in a Big Box shop with Epic access.

*Epic access can be granted by the Big Box shops to have limited access to their system, i.e. you get to see everyone else's notes. You can explore getting this access. I attempted to do this early in my PP opening days but realized it wasn't really that necessary, and stopped the process. Plus I have several large Big Box shops in area wasn't worth vying for all of them. I pick up the phone and chase people down when necessary.

 

[forchinet121]

Do you get record updates every time you see them? I don’t trust patients to accurately report (low functioning, memory problems, straight up want to hide things).

I have a feeling you are practicing in a way that the vast vast majority are not practicing and that is contributing to your issues. I do not do any of what you suggested on a regular basis

 

[lockian]

I have a feeling you are practicing in a way that the vast vast majority are not practicing and that is contributing to your issues. I do not do any of what you suggested on a regular basis

Im in a big box shop I can just eyeball certain areas of the chart and it does not take that long. I do not need to request anything, but if I were in PP I probably would and that would take phone calls, faxes, calls, etc.

I feel that an accurate understanding of health problems and other meds is key. Drug interactions kill, and a person who wants ADHD meds has every reason to conceal a heart problem. Coordination of care saves lives, and I am not sure, to be honest, that a lot of freestanding clinics can do it effectively or efficiently, unless you do in fact request Epic access to the big box shops.

But you are right on another thing. I need to learn to do less, to not think that I can control/am responsible for everything. I have recently realized that I feel a lot of pressure, likely self inflicted, to do a lot in every appointment, and to come up with a solution that meets a high standard that may not even be attainable.

 

[Sushirolls]

The other variable in this, Big Box shops, you will likely have more of those cognitively impaired, and medically complex patients. In PP you will simply have less of them.

The connected E-Rx tool that Luminello uses, for most patients, has the ability to tap in to the pharmacy, so you can see which meds they are getting filled, and I've picked up a few more complete med lists that patients forgot about.

 

[hallowmann]

Im in a big box shop I can just eyeball certain areas of the chart and it does not take that long. I do not need to request anything, but if I were in PP I probably would and that would take phone calls, faxes, calls, etc.

I feel that an accurate understanding of health problems and other meds is key. Drug interactions kill, and a person who wants ADHD meds has every reason to conceal a heart problem. Coordination of care saves lives, and I am not sure, to be honest, that a lot of freestanding clinics can do it effectively or efficiently, unless you do in fact request Epic access to the big box shops.

But you are right on another thing. I need to learn to do less, to not think that I can control/am responsible for everything. I have recently realized that I feel a lot of pressure, likely self inflicted, to do a lot in every appointment, and to come up with a solution that meets a high standard that may not even be attainable.

There are other ways to get around some of what you said, but generally I agree with you. I really worried about this, but you get used to not knowing things pretty quickly (within months), because patients need to be seen and treated whether you have 100% of the information or not. You rely more on other ways of management, you are probably more careful than you need to be, you unfortunately repeat labs or diagnostics that have already been done for your peace of mind (healthcare waste), and you get excited when you actually get records from another place.

My psychiatric care would be much better if I had more automatic access to these things, and I remember how comforting it was to look in EPIC and see decades of records leading to a patient's FPE. This is actually the argument for EMR, but unfortunately it has instead more than anything become a way to gather data on patients to optimize "workflow" (i.e. seeing more patients with less time each) and better "cater" (i.e. sell) care and as a billing tool.

What you'll find outside of these places is not necessarily that your care is worse, but that there are a lot of holes in both systems. I see care duplication all the time because the big box doesn't know I already got X,Y,Z on the patient. I personally am for a universal EMR shared by all organizations, and I wish EPIC-based organizations were better at being on board with this, but its quite variable.

*Epic access can be granted by the Big Box shops to have limited access to their system, i.e. you get to see everyone else's notes. You can explore getting this access. I attempted to do this early in my PP opening days but realized it wasn't really that necessary, and stopped the process. Plus I have several large Big Box shops in area wasn't worth vying for all of them. I pick up the phone and chase people down when necessary.

For reference: EHR Interoperability From Anywhere | Epic

 

[lockian]

The other variable in this, Big Box shops, you will likely have more of those cognitively impaired, and medically complex patients. In PP you will simply have less of them.

The connected E-Rx tool that Luminello uses, for most patients, has the ability to tap in to the pharmacy, so you can see which meds they are getting filled, and I've picked up a few more complete med lists that patients forgot about.

Sophisticated (and not so sophisticated) drug seekers gravitate toward private practitioners when records of their behaviors are all over the Big Box shops’ EMRs. I guess things like PMP can offer clues, but not the full story.

 

[randomdoc1]

Sophisticated (and not so sophisticated) drug seekers gravitate toward private practitioners when records of their behaviors are all over the Big Box shops’ EMRs. I guess things like PMP can offer clues, but not the full story.

I once had a very sophisticated one get an insurance rep on the phone on threeway saying I was denying her care just because she's on a benzo and won't let her schedule as a new patient in the clinic due to discriminatory practices. My response was "contrary to her saying she does not have a psychiatrist, PDMP shows she indeed does and she's flagged in the PDMP system. It appears based on this information, her history may have complexity and she benefits from staying in the healthcare system she's already in, for continuity of care. Oh, and btw, please stop calling us, you called us multiple times already with different stories." Gold.

 

[MedMan80]

I once had a very sophisticated one get an insurance rep on the phone on threeway saying I was denying her care just because she's on a benzo and won't let her schedule as a new patient in the clinic due to discriminatory practices. My response was "contrary to her saying she does not have a psychiatrist, PDMP shows she indeed does and she's flagged in the PDMP system. It appears based on this information, her history may have complexity and she benefits from staying in the healthcare system she's already in, for continuity of care. Oh, and btw, please stop calling us, you called us multiple times already with different stories." Gold.

This is the beauty of PP

 

[Mad Jack]

Im in a big box shop I can just eyeball certain areas of the chart and it does not take that long. I do not need to request anything, but if I were in PP I probably would and that would take phone calls, faxes, calls, etc.

I feel that an accurate understanding of health problems and other meds is key. Drug interactions kill, and a person who wants ADHD meds has every reason to conceal a heart problem. Coordination of care saves lives, and I am not sure, to be honest, that a lot of freestanding clinics can do it effectively or efficiently, unless you do in fact request Epic access to the big box shops.

But you are right on another thing. I need to learn to do less, to not think that I can control/am responsible for everything. I have recently realized that I feel a lot of pressure, likely self inflicted, to do a lot in every appointment, and to come up with a solution that meets a high standard that may not even be attainable.

Perhaps the best advice I was ever given was "don't work harder than your patients." They are autonomous adults, it is not on you to move heaven and earth to care for them. If they are unable to provide you with records or accurately account for their history, do what is within reason, but part of receiving care is participating in that care. Attempting to go above and beyond for every patient every time will burn you out unless you've got a very small private panel that is paying you well, and even then you might still find yourself extra crispy.

 

[Desired Member]

I empathize with OP when they mentioned patients who can't remember their meds. A huge portion, if not the majority, of my patients, have NO IDEA what meds they are taking let alone the doses, and when I eventually get a med list from a pharmacy, there are duplications in meds with multiple different doses listed, 10 different prescribing doctors, unclear what they should be taking due to their multiple recent hospitalizations, some go to multiple pharmacies in various cities across the state, etc. And often they have medical comorbidities such as diabetes and hypertension and they don't see their primary care much (or even have a primary care). So when they come in with significant psych symptoms, do you continue their psych meds or prescribes psych meds that will exacerbate their conditions or potentially have a med interaction? Or do you say that you won't continue their psych meds or prescribe any new ones because you don't have their med list or records?

 

[smalltownpsych]

I empathize with OP when they mentioned patients who can't remember their meds. A huge portion, if not the majority, of my patients, have NO IDEA what meds they are taking let alone the doses, and when I eventually get a med list from a pharmacy, there are duplications in meds with multiple different doses listed, 10 different prescribing doctors, unclear what they should be taking due to their multiple recent hospitalizations, some go to multiple pharmacies in various cities across the state, etc. And often they have medical comorbidities such as diabetes and hypertension and they don't see their primary care much (or even have a primary care). So when they come in with significant psych symptoms, do you continue their psych meds or prescribes psych meds that will exacerbate their conditions or potentially have a med interaction? Or do you say that you won't continue their psych meds or prescribe any new ones because you don't have their med list or records?

Not knowing their medications is passive coping which correlates with poorer outcomes. Unless they are significantly intellectually disabled or pre-adolescent children, patients can know what medications they are taking and why. Often our treatment places them in and/or reinforces a passive stance. It’s a mess to clean up from a medical stance, and that’s for you as the psychiatrist to deal with 😉, but I always start therapy with not allowing them to play the ”I don’t know card” and just get away with it. I do it gently and from an empowering stance and if they actually want to take some ownership of their treatment and by extension their life, then we can get off to a good start. If they want to remain a helpless victim then I know I don’t want to work harder than them so they usually find another person who is “nicer” aka not good with setting appropriate boundaries.

 

[Desired Member]

Not knowing their medications is passive coping which correlates with poorer outcomes. Unless they are significantly intellectually disabled or pre-adolescent children, patients can know what medications they are taking and why. Often our treatment places them in and/or reinforces a passive stance. It’s a mess to clean up from a medical stance, and that’s for you as the psychiatrist to deal with 😉, but I always start therapy with not allowing them to play the ”I don’t know card” and just get away with it. I do it gently and from an empowering stance and if they actually want to take some ownership of their treatment and by extension their life, then we can get off to a good start. If they want to remain a helpless victim then I know I don’t want to work harder than them so they usually find another person who is “nicer” aka not good with setting appropriate boundaries.

The patients I'm talking about have psychosis and usually current or past severe substance abuse disorders. I don't think they are playing the "I don't know card." It's very time-consuming care for these patients safely. It's not about "working harder than them", it's about providing safe care. Not sure why you thought it would be helpful to comment on a post about psychiatrist burnout that "it's a mess to clean up from a medical stance" and "that's for you as the psychiatrist to deal with" winky face

 

[clausewitz2]

The patients I'm talking about have psychosis and usually current or past severe substance abuse disorders. I don't think they are playing the "I don't know card." It's very time-consuming care for these patients safely. It's not about "working harder than them", it's about providing safe care. Not sure why you thought it would be helpful to comment on a post about psychiatrist burnout that "it's a mess to clean up from a medical stance" and "that's for you as the psychiatrist to deal with" winky face

One of the ways to be less burnt out is to assume less responsibility for the outcomes of your patients. Unfortunately the mental health system absolutely socializes lots of people with psychotic disorders into passive coping and so while some may be genuinely cognitively impaired to the point they can't understand its more an issue of desire/motivation than capability. I don't know a good way to crack this nut for chronic folks who have been professional mental patients for decades but forcing people earlier on to assume some responsibility for their own recovery is definitely important.

 

[smalltownpsych]

The patients I'm talking about have psychosis and usually current or past severe substance abuse disorders. I don't think they are playing the "I don't know card." It's very time-consuming care for these patients safely. It's not about "working harder than them", it's about providing safe care. Not sure why you thought it would be helpful to comment on a post about psychiatrist burnout that "it's a mess to clean up from a medical stance" and "that's for you as the psychiatrist to deal with" winky face

Was attempting to validate that it is a difficult thing to do and balance the psychological dynamics of a case. Hopefully implying that other members of the treatment team need to share the load. Many therapists would also take or reinforce a passive stance re: medication and that isn’t helpful either. Patients with long history of psychosis and substance abuse are obviously some of the most difficult to treat and hardest to cope with from a burnout stance for all of the people involved so working together is essential.

 

[vanfanal]

I feel like psychiatrists, or maybe just me, take on patient outcomes a lot more personally than other specialities, which makes us more prone to burn out. I feel like when a CHF patient who’s non compliant and with mutiple hospital admissions eventually dies, it’s seen as a medical complication of a non compliant patient, a natural eventuality. Nobody gets sued for that. But when you have someone with borderline PD or dysthymia who’s in and out with suicide and self harm attempts, it’s seen differently, like the psychiatrist isn’t doing enough or failed in some way. Suicide is seen differently from deaths in other fields of medicine.

I’m early career too. And luckily I had good psychodynamic background in training. So in my head I feel I more clearly delineate be between an endogenous depression which is med responsive, and a reactive depression which likely won’t be fixed by meds long term and needs meaningful therapy, which most can’t get access to. The moral injury for me is being stuck between what is right and, meeting expectations and demand. In the end, we’re all pulled to want to help.

So for the dysthymics, PDs, reactive depressions, what is the “standard of care” when they can’t access therapy and I’m not equipped to give it? Most pts don’t understand that notion that there isn’t a pill to fix every ill, they’ve been convinced that any negative feeling is a chemical imbalance. In the end I’m left cycling through trials of antidepressants, while still trying to be reasonable, unlike others out in the community who will have such patient of ever class of med at the same time- SSRI, SGA, benzo, stimulant and now medical cannabis.

 

[calvnandhobbs68]

I feel like psychiatrists, or maybe just me, take on patient outcomes a lot more personally than other specialities, which makes us more prone to burn out. I feel like when a CHF patient who’s non compliant and with mutiple hospital admissions eventually dies, it’s seen as a medical complication of a non compliant patient, a natural eventuality. Nobody gets sued for that. But when you have someone with borderline PD or dysthymia who’s in and out with suicide and self harm attempts, it’s seen differently, like the psychiatrist isn’t doing enough or failed in some way. Suicide is seen differently from deaths in other fields of medicine.

I think this is just something psychiatrists tell themselves as a group for some reason. As has been noted many times before, psychiatry is statistically the LEAST likely speciality to be sued and the most likely reason psychiatrists are sued are for patient suicides, many of these lawsuits then end up being thrown out or settled easily because it's actually so difficulty to casually determine that any series of particular medical decisions lead to this outcome. So the actual numbers argue quite a bit away from the idea that people (and the legal system) really view suicide different from other deaths and assign more blame to psychiatrists than other physicians.
People absolutely get sued for a non compliant CHF patient dying.

 

[surfguy84]

In a productivity-based system I'm not sure why people do this to themselves. I get it in a Kaiser-style system where the goal is to serve a set number of people, but if you are in a productivity-based system this approach does not make sense.

You already have up to 5 hours of follow ups. If those are 30-minute E&M plus therapy slots, that is quite a bit. The three intakes probably take at least 1.5 hours of work (chart review, evaluation, any orders or care coordination, and charting). Under the old RVU system I'm most familiar with that yields about 3.8 RVUs for 1.5 hours of work. A follow-up (30 mins) is 3 RVUs for 30 minutes of work.

The strategy that makes the most sense from almost every angle is to see new patients for frequent follow-up. I often start out with weekly 30-minutes sessions. New patients are often the least stable and appreciate this level of attention. You can actually have time to do CBT-i, brief CBT or supportive therapy, behavioral activation work, etc. etc. You also see them frequently so that out-of-session contact (calls, messages etc) can be minimized. Because you see them so often, it's typically easy to fit all needed work into the 30-minute block.

In contrast, if you flood your nearly-full panel with lots of intakes you will often need to space out follow-ups more. That makes more room for intakes (which reimburse lower) while simultaneously limiting your follow-up slots and making managing those more acute patients harder. It is an all around losing proposition. The only real benefit is access for new patients, but honestly you can't help everyone. If you focus on high quality care for your existing panel (which you gradually expand) the job becomes a lot easier and more fulfilling. At least I imagine it does, I have never agreed to do anything like 3 new outpatient intakes every day.

How much frequency will insurance support before they deny reimbursement?

 

[Desired Member]

Was attempting to validate that it is a difficult thing to do and balance the psychological dynamics of a case. Hopefully implying that other members of the treatment team need to share the load. Many therapists would also take or reinforce a passive stance re: medication and that isn’t helpful either. Patients with long history of psychosis and substance abuse are obviously some of the most difficult to treat and hardest to cope with from a burnout stance for all of the people involved so working together is essential.

Thanks for clarifying. I legitimately think these patients can’t remember (e.g. history of TBI, been hospitalized 50+ times, withdrawing from a substance, years of inadequately treated psychosis for various reasons). Have petitioned for guardianship for some of these patients. Psychotic patients typically don’t want therapy, at least in my experience.

 

[smalltownpsych]

Thanks for clarifying. I legitimately think these patients can’t remember (e.g. history of TBI, been hospitalized 50+ times, withdrawing from a substance, years of inadequately treated psychosis for various reasons). Have petitioned for guardianship for some of these patients. Psychotic patients typically don’t want therapy, at least in my experience.

Yeah, those folk are pretty far gone and don’t trust anyone in the system and especially the therapists and usually for very good reasons. In my experience, many of the “therapists” in the systems that work with these individuals don’t have a clue as to what therapy really is and just tell patients what to do and then try to control them in some way when they are “non-compliant” and then blame the illness for it which is partially true especially with substance users who tend to be a pretty defiant group.