Where are my community mental health center psychiatrists at?

[forchinet121]

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

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

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

The same way you solve any other problem..you increase funding and pay for qualified professionals..I bet if they could pay 500k there would be a list to work in rural areas..instead they have the worst pay sometimes so no one wants to go there..the answer isn’t to fill the place with unqualified people

---

Members don't see this ad.

 

[When is graduation again?]

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

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



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



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

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

I disagree with your comment about those drawbacks being applicable across psychiatry. On my last check, the SPMI population has a life expectancy that's 17 years less than general population. I have a significant number of patients in their 40s that will probably die within the next 3-4 years w/ 1 or 2 who will likely die in the next 6 months. When you're spending time with people in their community and in their homes, when they die unnecessarily early it hits different. Zero control over patients is a lot different when their lives are often already in turmoil and they choose paths that keep them in chronic homelessness or lead to unnecessary eviction, which feels like a near biweekly occurrence. I even had a patient who was murdered recently, likely due to a series of very poor decisions they made when psychiatrically stable. Treatment-resistance is seen in many areas of psychiatry, but the degree of treatment-resistant psychosis is heaviest in the ACT model, since by definition, we're taking patients with frequent hospitalizations or who are discharged from state hospitals. I have a few patients that should really be in state hospitals, but the waitlists are too long, so we do are best to keep them safe in the community.

You're right about call being present across medicine, of course, but I included it for full transparency. And the management situation at CHMC's is by in large way worse than other aspects of psychiatry. Even in this thread, there are tons of examples of how awful it can be. There's a reason turnover is so high at these facilities. The degree of mismanagement at my current facility is scales above anything I saw (and complained about) in residency.

Your final point about CHMC screening is accurate. My organization seemingly hires people off the street with no clinical background to triage to the different teams. I've learned to ignore their evaluations because they are flagrantly wrong most of the time. It took a real struggle just to get them to request medical records from the referral sources because they wanted to take as many patients as possible, even when the patients were clinically inappropriate and high risk for potentially hurting staff members. Of course, they do it for the money. My team has been able to push back on this so far, but if numbers aren't being generated, there's only so long that they'll let you try for quality care.

 

[Coupd'Cat]

I disagree with your comment about those drawbacks being applicable across psychiatry. On my last check, the SPMI population has a life expectancy that's 17 years less than general population. I have a significant number of patients in their 40s that will probably die within the next 3-4 years w/ 1 or 2 who will likely die in the next 6 months. When you're spending time with people in their community and in their homes, when they die unnecessarily early it hits different. Zero control over patients is a lot different when their lives are often already in turmoil and they choose paths that keep them in chronic homelessness or lead to unnecessary eviction, which feels like a near biweekly occurrence. I even had a patient who was murdered recently, likely due to a series of very poor decisions they made when psychiatrically stable. Treatment-resistance is seen in many areas of psychiatry, but the degree of treatment-resistant psychosis is heaviest in the ACT model, since by definition, we're taking patients with frequent hospitalizations or who are discharged from state hospitals. I have a few patients that should really be in state hospitals, but the waitlists are too long, so we do are best to keep them safe in the community.

You're right about call being present across medicine, of course, but I included it for full transparency. And the management situation at CHMC's is by in large way worse than other aspects of psychiatry. Even in this thread, there are tons of examples of how awful it can be. There's a reason turnover is so high at these facilities. The degree of mismanagement at my current facility is scales above anything I saw (and complained about) in residency.

Your final point about CHMC screening is accurate. My organization seemingly hires people off the street with no clinical background to triage to the different teams. I've learned to ignore their evaluations because they are flagrantly wrong most of the time. It took a real struggle just to get them to request medical records from the referral sources because they wanted to take as many patients as possible, even when the patients were clinically inappropriate and high risk for potentially hurting staff members. Of course, they do it for the money. My team has been able to push back on this so far, but if numbers aren't being generated, there's only so long that they'll let you try for quality care.

My experience is similar to yours. It is difficult to watch people die, slowly or all of a sudden, from personal choice, external systemic factors, or a combination/repetitive cycle of both. It's also hard to stomach how the mental health system/state itself dresses up its harm as "trauma-informed" or "recovery oriented" while labeling people and throwing them into some sort of assembly line shuffle that is more insane than any of my patients are. I have a few people in their twenties already with fatty liver disease. Two patients have BMIs > 70. High cholesterol all over the place.

I think the three most important things I have done in my first six months has been 1) deprescribe 2) see people more often and for longer periods of time, with the added satisfaction that this extra TLC appears to magically alleviate everything from depression to anxiety to psychosis 3) give the illusion that they have self-control and autonomy over their own medications in hopes that this would eventually be true to some extent. So far the meaningfulness of being able to practice this way--because management/insurance leave me alone--outweighs the anxiety of having little control over risky situations and the grief of witnessing the downstream effects of policy decisions in the U.S. such as lack of basic childcare and support for poor families, criminalization and over-policing, child "protection" and ripping apart of families, lack of school-based mental health, and incentivization of companies to produce good-tasting garbage instead of nutritional food, etc.

 

[ArdorAyurveda]

Originally, I wanted to do community psychiatry, but I really just see myself opening a private practice after a while and doing pro bono work when I can. Generally seems like the CMHCs, ACT, IOPs and PHPs don't really pay that well. Might do still do correctional psychiatry and work with Native American populations though, that seems fun and good opportunity to work with underserved populations

 

[Cath Up]

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



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

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

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

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

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

PGY1 here- reading frequently! This is a great thread, thank you for starting it.

For anyone- would you be able to work in a CMHC with the caveat that you refuse to oversee NPs or teach NP students?

 

[Lunzio]

PGY1 here- reading frequently! This is a great thread, thank you for starting it.

For anyone- would you be able to work in a CMHC with the caveat that you refuse to oversee NPs or teach NP students?

From my limited experience, there are some CMHCs that save APRN oversight for the medical director.

 

[Coupd'Cat]

PGY1 here- reading frequently! This is a great thread, thank you for starting it.

For anyone- would you be able to work in a CMHC with the caveat that you refuse to oversee NPs or teach NP students?

From my limited experience, there are some CMHCs that save APRN oversight for the medical director.

It's certainly possible, and I work in one of these settings. Our APRNs are supervised by the medical director, only. There are a few PA students which the medical director assigns to one or two psychiatrists who have the time to teach them. The nearby CMHC which is affiliated with an academic institution has no APRNs, last time I spoke with those who work there. In part, it has relatively little trouble attracting psychiatrists due to the academic affiliation.

It's good to be thinking already about whether you would want to supervise NPs/NP students (and it sounds like you do not), as these would be issues to bring up in your job search and negotiations. Glad you're thinking about working in a CMHC even as a PG1.

 

[ObsequiousAplomb]

PGY1 here- reading frequently! This is a great thread, thank you for starting it.

For anyone- would you be able to work in a CMHC with the caveat that you refuse to oversee NPs or teach NP students?

You can find some jobs that do. A better route would be to attempt to gain experience in training that prepares you for supervision / training / working alongside midlevels. Programs that completely avoid midlevels end up with graduates who remain completely uncomfortable working with them.

 

[smalltownpsych]

My experience is similar to yours. It is difficult to watch people die, slowly or all of a sudden, from personal choice, external systemic factors, or a combination/repetitive cycle of both. It's also hard to stomach how the mental health system/state itself dresses up its harm as "trauma-informed" or "recovery oriented" while labeling people and throwing them into some sort of assembly line shuffle that is more insane than any of my patients are. I have a few people in their twenties already with fatty liver disease. Two patients have BMIs > 70. High cholesterol all over the place.

I think the three most important things I have done in my first six months has been 1) deprescribe 2) see people more often and for longer periods of time, with the added satisfaction that this extra TLC appears to magically alleviate everything from depression to anxiety to psychosis 3) give the illusion that they have self-control and autonomy over their own medications in hopes that this would eventually be true to some extent. So far the meaningfulness of being able to practice this way--because management/insurance leave me alone--outweighs the anxiety of having little control over risky situations and the grief of witnessing the downstream effects of policy decisions in the U.S. such as lack of basic childcare and support for poor families, criminalization and over-policing, child "protection" and ripping apart of families, lack of school-based mental health, and incentivization of companies to produce good-tasting garbage instead of nutritional food, etc.

100% agree with the first two points and really wish that more people in our field could see the reality of this. To the third point, I would say that by taking the perspective that the patient does indeed have autonomy will lead to them taking more responsibility for it. Power of expectancy. Healthy relationships are curative and improve almost all outcomes there is no doubt about that. Sometimes we are the only one capable of providing that healthy relationshi because everyone else in the patients life is trying to control them including the treatment team members.

 

[Cath Up]

You can find some jobs that do. A better route would be to attempt to gain experience in training that prepares you for supervision / training / working alongside midlevels. Programs that completely avoid midlevels end up with graduates who remain completely uncomfortable working with them.

Thank you for your response. I feel pretty strongly that I will never teach midlevel students- despite them probably being difficult to turn down on a personal level, I find it unethical to support a field whose defining feature is skipping training and asking for parity/to compete with psychiatrists.

To be able to play nice in the job market sand box, I would consider supervising 1-2 midlevels that I knew well and trusted. It is helpful to hear that working alongside them probably arbitrarily cuts down on the jobs open to a psychiatrist, so I'd try to be open to at least working alongside but not overseeing them as well. But the nonsense of working with 3-4 or just staffing a few patients with the clinic NP you have no relationship with will hopefully remain difficult for me to stomach.

 

[justalittlestar]

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

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

Are you in a metro area?