how much time do you need to see 15 inpatients?

[Ahamis]

It seems that most of the inpatient jobs have a patient census of 14-17 beds. My colleague was telling me that he finishes writing notes around noon-1PM. And depending on the hospital, you could leave after that and just answer calls. So, he believes it is more advantageous to do inpatient than outpatient. His argument is that with outpatient you will be seeing patients from 9 to 5 non-stop.

For those who have inpatient jobs, how much time do you need to evaluate (and document) 15 patients?

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[hamstergang]

So, he believes it is more advantageous to do inpatient than outpatient.

Even for half the time of outpatient I wouldn't do inpatient as I just hate that work.

Anyway, some of this depends on turnover as new patients and discharged take more time than follow ups. Also depends on support staff to some degree. But I don't know the answer -- just throwing some stuff out there.

 

[grapefruit17]

Granted I'm just a resident, but every other weekend on inpatient I have to round on the entire unit of 14, with the notes its not very fun. Plus pts/nurses always stop me making it longer

 

[Nephro critical care]

Edited.
Sorry my mistake. Posted in the wrong forum. Incorrectly assumed to be a hospitalist thread.

 

[jaymon]

It kind of depends upon how many days are you into your block of hospitalist shifts. On day 1 Everyone was new for me and it was not atypical for me to be here till 8 writing notes on 14-17 patients. But on follow up days things got quicker and I was able to finish around 1-2 pm. It also depends on if you have ICU patients and if you are managing them primarily or the intensive staff is.
An ICU patient can eat up 3-4chrs especially on day of admission if you are primarily managing.

Are you a psychiatrist? Why are you managing ICU patients, if so?

Sent from my SM-G955U using Tapatalk

 

[nexus73]

IMO 14+ patients per day sucks. This is a full day, of you're doing a decent job. While I don't know your colleague or how he practices, if he's seeing that many people and finishing by 1, he's not doing great work and is probably missing things.

 

[ryerica22]

I would manage these many patients and finish my notes within the time span of 8AM-2/3PM. I feel like I would do a half decent job and would take 30 minute lunch break.

 

[Ahamis]

IMO 14+ patients per day sucks.

It seems to be very common to have a census of 14-15 patients. Except, if you work at VA...

 

[benlinus]

15-18 patient load is commonplace on inpatient units; 8am-3pm sounds about right; get there early and do your admissions and discharges first, then round on the follow-ups; hospitals commonly have some time cutoff in place to disrupt the admissions at say 5pm, usually cut off is around 12pm-2pm for new patients for the day, can just see them the next morning

 

[nexus73]

It seems to be very common to have a census of 14-15 patients. Except, if you work at VA...

Is this based on 7 on 7 off schedule or typical M-F? I also think it's gotta depend on location. Bigger cities have more supply of psychiatrists and can work them harder.

 

[NJWxMan]

On a respected, high quality voluntary inpatient unit staffed with experienced nurses and psychiatrists, 45 min/patient is the expected average. This includes notes, family meetings, tx team meetings as well.

 

[hebel]

As a PGY-2, I was wondering how you eventually get so much faster? Most days my inpatient list is about 8 patients and I often struggle to get all the work done between 8-5pm. My notes really don't take that long anymore (often less than 10min)...it's mostly from my day evaporating away after seeing the patients (some need like 30-45 minutes of psychotherapy time), doing prior auths, calling collateral, having family meetings, etc..

So how do you guys do it and still feel like you're doing a solid job?

 

[ryerica22]

As a PGY-2, I was wondering how you eventually get so much faster? Most days my inpatient list is about 8 patients and I often struggle to get all the work done between 8-5pm. My notes really don't take that long anymore (often less than 10min)...it's mostly from my day evaporating away after seeing the patients (some need like 30-45 minutes of psychotherapy time), doing prior auths, calling collateral, having family meetings, etc..

So how do you guys do it and still feel like you're doing a solid job?

I never did much therapy when I was in the inpatient. I also rarely ever did prior authorizations, always used affordable meds. Collateral was typically done by Social Workers. Family meetings were done only if absolutely indicated (maybe once or twice a week).

 

[michaelrack]

Agree with ryeica22 above...general psych units for the non rich usually have psychologists or social workers do the psychotherapy

 

[Armadillos]

One of the biggest drains on time as a resident seemed to be evaluating/consulting people/coordinating care related to medical problems, my understanding is most private psych hospitals dealing with any non psych medical stuff is an internist or NP job?

 

[Ahamis]

Bigger cities have more supply of psychiatrists and can work them harder.

I can't understand how someone can see more than 15 patients per day (acute unit). The quality is probably negatively affected.

On a respected, high quality voluntary inpatient unit staffed with experienced nurses and psychiatrists, 45 min/patient is the expected average.

8 hours of work is equal to 480 minutes.
Based on your math, someone would need more than 11 hours to see 15 patients...
If you spend 45 minutes with each patient you would end up seeing only 10 patients in a day. I think very few places allow you to have such a low census, unfortunately.

.it's mostly from my day evaporating away after seeing the patients (some need like 30-45 minutes of psychotherapy time)

I believe that psychotherapy is done by SW or psychologists in many private hospitals.

 

[Psychotic]

As a PGY-2...it's mostly from my day evaporating away after seeing the patients (some need like 30-45 minutes of psychotherapy time)

You are a PGY-2? So a month or so out of intern year? And you are doing extensive psychotherapy on an inpatient unit?

So much about this is screwed up I don't know where to start...

 

[thoffen]

The answer depends on a lot of things. In many cases collection of clinical information, follow-up treatment decisions and arrangements, substance abuse counseling, family contact and meetings, medical care, etc. are all handled largely or fully by other team members, and the expectation of the psychiatrist is to use that external information to prescribe medications and sign things prepared by others.

Personally, I'm not sure I could get to the point of fully trusting the information handed to me. Nor would I be interested in limiting the development of treatment relationships. I don't think partitioning out the psychiatrist to such a narrow role makes quality care.

 

[grapefruit17]

family meetings are the bane of my existence since there's no easy way to say "ok it's been an hour let's stop talking now" and have people actually listen to that. Those are probably my least favorite aspect of psychiatry.

I don't do any therapy intern year I would have no idea where to even begin. But my day is eaten away by a lot of acute problems. Patient population here is pretty rough.

 

[hebel]

You are a PGY-2? So a month or so out of intern year? And you are doing extensive psychotherapy on an inpatient unit?

So much about this is screwed up I don't know where to start...

I think you're kind of jumping to conclusions. You really think 30-45 minutes of talking to maybe 2 out of 8 of your patients is "extensive psychotherapy." I completely agree that I'm no expert in therapy, and I use the term psychotherapy very loosely. Our program does have about 100 hours of supervised psychotherapy during intern year, so there's at least some framework there. It also seems like good form to talk to your patients...especially when they seem to benefit from it and it helps me understand the psychosocial factors better. What is crazy about that?

As for the collateral gathering, this would often include contacting family or friends to help determine a diagnosis. In the real world social workers usually do this?

Also, what would people consider an appropriate inpatient encounter? Should it be medication effect and sife-effects, how are you sleeping, then done (5-10minutes)? I'm asking seriously because I dont want to be mislead by my own units culture.

 

[SmallBird]

family meetings are the bane of my existence since there's no easy way to say "ok it's been an hour let's stop talking now" and have people actually listen to that. Those are probably my least favorite aspect of psychiatry.

I think its very important to get good at being able to end family meetings in the allotted time - it seems to be less a matter of skill, and more a capacity to tolerate negative affect. I had a very experienced attending who couldn't end the meeting before everyone had agreed on something. I do my best to tie things up but sometimes will acknowledge that some problems are going to take more to fix, and that its ok if we end the family meeting with much unresolved.

 

[thoffen]

family meetings are the bane of my existence since there's no easy way to say "ok it's been an hour let's stop talking now" and have people actually listen to that. Those are probably my least favorite aspect of psychiatry.

I don't do any therapy intern year I would have no idea where to even begin. But my day is eaten away by a lot of acute problems. Patient population here is pretty rough.

You'll probably have better success with agreeing on an allotted time before the meeting and declaring it over precisely when that time comes.

 

[HarryMTieboutMD]

Inpatient psychiatry is mostly revolving door... it sucks but that's the way it is. With that said I spend 10 minutes MAX talking to a patient after the initial H&P when I'm rounding- but I try to be efficient as possible. Our nurses document really well so chart rounding is a useful tool. For family meetings, I make them as brief as possible (and try to avoid families during non allotted times- this gets into boundary issues, etc).

 

[Ahamis]

I spend 10 minutes MAX talking to a patient after the initial H&P when I'm rounding

That is what my friend told me. By working in that rhythm you should be able to finish your work early.
And it seems that is how some psychiatrists are able to make more than 300-350k. They see inpatient in the morning and go to their clinic in the afternoon.

 

[GUH]

Also, what would people consider an appropriate inpatient encounter? Should it be medication effect and sife-effects, how are you sleeping, then done (5-10minutes)?

From how I've seen attendings round on continuing patients on inpatient units at several hospitals, yes. It can take longer if teaching is involved, though.

 

[ryerica22]

I think its very important to get good at being able to end family meetings in the allotted time - it seems to be less a matter of skill, and more a capacity to tolerate negative affect. I had a very experienced attending who couldn't end the meeting before everyone had agreed on something. I do my best to tie things up but sometimes will acknowledge that some problems are going to take more to fix, and that its ok if we end the family meeting with much unresolved.

I think I have that weakness in that I feel a great deal of empathy for what these families go through and they have a million questions at times. I really just don't enjoy talking to families in person to be honest, its easier for me to do it on the phone.

 

[J ROD]

When I am at the VA, I could see that many patients 8 am - 1 pm with no lunch and do solid work. Biggest slow down for me is having to do other work. If someone does the medical issues, social work, psychology, and family meetings and leave me just to see patients and manage medications, I can focus and do my Psychiatry part. Inpatient is about stabilization. I get them stable on medications and back to a place where they can be outpatient safely. The psychotherapy and such can be done outpatient. Another key factor is how many are new patients and h&p's are needed. That would slow me down.

 

[thoffen]

I think I have that weakness in that I feel a great deal of empathy for what these families go through and they have a million questions at times. I really just don't enjoy talking to families in person to be honest, its easier for me to do it on the phone.

That's not a weakness. But a good understanding of your role and that of others, family dynamics, reasonable treatment goals, etc. adds up to manageable family contact in my mind. Especially if you're in the (typical) revolving door scenario. By providing answers and reassurances to things which have already been sufficiently answered and reassured, you might be reinforcing a dynamic that is part of why things are a revolving door. It's much more appropriate to focus on families of patients who are presenting for the first time.

That said, there are a variety of reasons why someone with a well established illness may have not had important communication about their illness with them or their family and a lot of good can be had by addressing it.

 

[Jules A]

I tend to average 2-3 intakes/discharges a day so 15 patients generally take me between 5-7h if there are no unforeseen crisis or consults. I'm very middle of the road with speed and volume of documentation. The real time suck for me in most cases although in my opinion essential for collateral is treatment team with RNs and social workers. I almost never do family meetings that is what the social workers are for although on a rare occasion I will call family if I have been told they are reasonable and the information I'm seeking is something I really need to garner myself. I always call if a family member specifically requests to speak with me. In the cases I do call family I am as focused as possible in an effort to be efficient because this can easily lead into 20-30 minutes if you don't rein it in.

 

[cookymonster]

I suck at this. I wish it was like in residency where I can sit with my team in a group room and the nurses shepherd in my patients in a well-oiled assembly line, and I don't even have to get up or worry about anything else until the last patient is seen 2 or 3 hours later. My day just feels like constant chaos littered with extraneous waste.

I usually show up to work hoping to get out just after lunch, but these are some of the things that usually get me derailed:
Horrible new EMR that constantly freezes, crashes, and makes me complete redundant forms
Patients in the shower or bathroom, or meeting with the social worker when I need them
Messages, pages, and phone calls that come up as distractions at random times throughout the day
Difficulty tracking down RNs and other support staff
Pointless meetings that kill efficiency
Dislike using dragon and am unskilled technically with other computer software that could improve efficiency of documentation. I find myself frequently typing the same boilerplate phrases in notes all the time because I hate the process of creating dozens of saved autotexts (which then disappear)
Can't remember DSM-5 and ICD-10 codes worth a damn.
The culture of where I work has the MDs do excessive non-essential paperwork, including work excuses, FMLA, Medicaid eligibility forms
Calling pharmacies to figure out the patient's home meds (because no one else will do it)
Finding where the patient is on the unit, then finding a place where we can both sit down in private. Walking back and forth across a big unit all day.
Checking at the end of the day to make sure all of the bills I submitted electronically actually went through
Family meetings
ECT consults

 

[ryerica22]

I suck at this. I wish it was like in residency where I can sit with my team in a group room and the nurses shepherd in my patients in a well-oiled assembly line, and I don't even have to get up or worry about anything else until the last patient is seen 2 or 3 hours later. My day just feels like constant chaos littered with extraneous waste.

I usually show up to work hoping to get out just after lunch, but these are some of the things that usually get me derailed:
Horrible new EMR that constantly freezes, crashes, and makes me complete redundant forms
Patients in the shower or bathroom, or meeting with the social worker when I need them
Messages, pages, and phone calls that come up as distractions at random times throughout the day
Difficulty tracking down RNs and other support staff
Pointless meetings that kill efficiency
Dislike using dragon and am unskilled technically with other computer software that could improve efficiency of documentation. I find myself frequently typing the same boilerplate phrases in notes all the time because I hate the process of creating dozens of saved autotexts (which then disappear)
Can't remember DSM-5 and ICD-10 codes worth a damn.
The culture of where I work has the MDs do excessive non-essential paperwork, including work excuses, FMLA, Medicaid eligibility forms
Calling pharmacies to figure out the patient's home meds (because no one else will do it)
Finding where the patient is on the unit, then finding a place where we can both sit down in private. Walking back and forth across a big unit all day.
Checking at the end of the day to make sure all of the bills I submitted electronically actually went through
Family meetings
ECT consults

sounds likke a nightmare.

 

[Jules A]

I suck at this. I wish it was like in residency where I can sit with my team in a group room and the nurses shepherd in my patients in a well-oiled assembly line, and I don't even have to get up or worry about anything else until the last patient is seen 2 or 3 hours later. My day just feels like constant chaos littered with extraneous waste.

I usually show up to work hoping to get out just after lunch, but these are some of the things that usually get me derailed:
Horrible new EMR that constantly freezes, crashes, and makes me complete redundant forms
Patients in the shower or bathroom, or meeting with the social worker when I need them
Messages, pages, and phone calls that come up as distractions at random times throughout the day
Difficulty tracking down RNs and other support staff
Pointless meetings that kill efficiency
Dislike using dragon and am unskilled technically with other computer software that could improve efficiency of documentation. I find myself frequently typing the same boilerplate phrases in notes all the time because I hate the process of creating dozens of saved autotexts (which then disappear)
Can't remember DSM-5 and ICD-10 codes worth a damn.
The culture of where I work has the MDs do excessive non-essential paperwork, including work excuses, FMLA, Medicaid eligibility forms
Calling pharmacies to figure out the patient's home meds (because no one else will do it)
Finding where the patient is on the unit, then finding a place where we can both sit down in private. Walking back and forth across a big unit all day.
Checking at the end of the day to make sure all of the bills I submitted electronically actually went through
Family meetings
ECT consults

This does sound miserable. In general my expectation for my full time job is not to leave around lunch time although I love it on the rare occasion it happens so it might help if you adjust that expectation going in. Here are some modifiable factors that could make life easier although some might involve changing the culture which takes time and can be initially painful:

1. Dragon is your friend. Take the time to get comfortable with it and either create or plagiarize the phrases used most inparticular intake/discharge like "prognosis fair provided patient is adherent to agreed upon regimen and follows up with aftercare as recommended and arranged". If you really can't learn dragon make a Word Doc that you can copy/paste from.
2. Make a list of the DSM-5 and ICD-10 codes used most often. Its probably not that extensive.
3. Unless you are the medical director I'd decline any meetings that don't apply to me personally. Same with family meetings, in most cases they are a vehicle for me to have social workers ask a key question or two, there is no reason except in extremely rare instances or a VIP that I'm ever in a family meeting.
4. Your nurses should be assisting with med reconciliation. I only call the pharmacy in cases where something looks off or its easier to just call than to hunt the RN down and ask them to do it.
5. You should be only a signature and maybe offer minimal verbal assistance with regard to FLMA, work notes etc. That is something your social workers or secretary should be doing. Its unfortunate that this wasn't shut down the first time someone handed you a stack of blank papers to fill out so unfortunately you may need to enlist the help of your medical director who can approach their manager.
6. Hunting patients down is annoying so I initially make a swep of all the bedrooms and although there are pros and cons if the patient is lounging in bed thats where I do it. If not always pick the closest spot because walking a long hall with 15+ patients even if its only 1 minute each way can eat a 1/2 hour.
7. Probably the best advice I can offer, and I'm sure this will offend someone's sensibilities, is to shamlessly suck up to your support staff. I feed and praise them often. A box of pastries seems to buy an exponential amount of good will. At the very least if you are nice they will be inclined to do more for you, even if not technically their job, than if you are a butt.

 

[Ahamis]

I suck at this. I wish it was like in residency where I can sit with my team in a group room and the nurses shepherd in my patients in a well-oiled assembly line, and I don't even have to get up or worry about anything else until the last patient is seen 2 or 3 hours later. My day just feels like constant chaos littered with extraneous waste.

I usually show up to work hoping to get out just after lunch, but these are some of the things that usually get me derailed:
Horrible new EMR that constantly freezes, crashes, and makes me complete redundant forms
Patients in the shower or bathroom, or meeting with the social worker when I need them
Messages, pages, and phone calls that come up as distractions at random times throughout the day
Difficulty tracking down RNs and other support staff
Pointless meetings that kill efficiency
Dislike using dragon and am unskilled technically with other computer software that could improve efficiency of documentation. I find myself frequently typing the same boilerplate phrases in notes all the time because I hate the process of creating dozens of saved autotexts (which then disappear)
Can't remember DSM-5 and ICD-10 codes worth a damn.
The culture of where I work has the MDs do excessive non-essential paperwork, including work excuses, FMLA, Medicaid eligibility forms
Calling pharmacies to figure out the patient's home meds (because no one else will do it)
Finding where the patient is on the unit, then finding a place where we can both sit down in private. Walking back and forth across a big unit all day.
Checking at the end of the day to make sure all of the bills I submitted electronically actually went through
Family meetings
ECT consults

I'm sorry to hear that. It sounds like my inpatient VA rotation.
Which EMR do you use?

 

[cookymonster]

We use Cerner. It is the pits. The problem is that we've implemented a lot of click-box forms that are resistant to dictation and other efficiency hacks. The coders and UR are also always making them more complicated and redundant, and it is pretty difficult to put much effort into them. I wish we had CPRS, it's probably the best EMR I've used.

I thought being a science major was the best preparation for being a physician. Now I'm telling all the pre-meds I know to major in computer science.

I guess I'll have to spend a few hours with a dragon coach. I've been trying to use word but it isn't working that well.

 

[thoffen]

If you have no sway to get support for even patients being available when you are rounding, then look for something else. Sure, you can get better at the EMR, ICD-10 codes, etc. but their culture sounds as though it doesn't support physicians.

 

[smalltownpsych]

Talking to patients for 45 minutes does not make it psychotherapy and is often a waste of resources in an acute unit. I have to talk to the patients for 18 minutes so that I can bill and even then it is a stretch at times since the acute unit is rarely the best place to provide much in the way of psychotherapy. On the acute unit it is all about stabilize and dispo. Now acute might mean different things in different places. Here it is 1 to 4 days. If the person is there for a week or two, then I am doing more psychotherapy with those who would benefit.