Good topics to discuss with residents starting outpatient psych?

[ResidentAnonymous001]

Hi all,

What are some good topics to discuss with residents starting outpatient psych? Any ideas or advice is appreciated!

---

Members don't see this ad.

 

[rjs2131]

Billing/coding (especially how to use therapy add-on codes), how to structure your visits to be efficient with note-taking + meet insurance requirements, how to structure a focused visit to avoid getting overwhelmed with all of the patient's problems and trying to hone in on what is most relevant.

 

[clausewitz2]

Billing/coding (especially how to use therapy add-on codes), how to structure your visits to be efficient with note-taking + meet insurance requirements, how to structure a focused visit to avoid getting overwhelmed with all of the patient's problems and trying to hone in on what is most relevant.

This is absolutely the critical learning task of the outpatient years. Inpatient or ED it is much easier to keep your focus tight, there are a limited number of moves you have. Outpatient, you drown if you aren't ruthless about this (especially if you can't arrange for relatively frequent follow-up).

 

[Celexa]

I spend a lot of time un-teaching inpatient psychopharm habits. No not everyone needs max doses. Yes it's OK to be patient. No you don't have to make a med change every day.

Also, inbox management and boundaries (being reliable but not reactive in getting back to patients, etc).

 

[Celexa]

Oh, and another critical inpatient thing to unwind--the goal of inpatient is to be well enough to be discharged. The goal of outpatient is to be well . Totally different and easy to forget.

 

[Stagg737]

Imo the two biggest things I see being issues that aren't obvious are making sure there are actual goals of care and how to set and maintain boundaries. Can't say how often docs just throw meds at patients for years and then I see the patient and find out their "depression" or "anxiety" or insert-problem-here was something completely different that wasn't particularly difficult to address. Or those patients who are always "depressed" or "anxious" but just have unrealistic expectations of what their life is supposed to be like. Being able to have an idea of what the actual goal for the next few appointments vs years later often makes a massive difference. Boundaries is pretty self-explanatory, but monitoring countertransference and how patients make the residents feel is helpful both for their clinical skills and their own mental health.

This is absolutely the critical learning task of the outpatient years. Inpatient or ED it is much easier to keep your focus tight, there are a limited number of moves you have. Outpatient, you drown if you aren't ruthless about this (especially if your can't arrange for relatively frequent follow-up).

I agree with this and would say this is part of why I hate outpatient. Sometimes the problem is easy to identify and keep narrow with treatment. However, once you get more into the optimization phase of treatment things get much more cloudy in terms of what we can/should help with.

Oh, and another critical inpatient thing to unwind--the goal of inpatient is to be well enough to be discharged. The goal of outpatient is to be well . Totally different and easy to forget.

This is true, but I think it's equally important to define what being "well" actually means. Many patients have an unrealistic expectation that we can help them feel happy all or most of the time or that they shouldn't have to feel sad or anxious. Understanding that educating these patients on what we can actually do and that negative feelings are not only normal but healthy and important is something I feel many outpatient psychiatrists rarely talk about. Especially those doing the 15 minute med-check appointments.

 

[mistafab]

workflow (timely/effective/efficient notes), and boundaries.

 

[clausewitz2]

This is true, but I think it's equally important to define what being "well" actually means. Many patients have an unrealistic expectation that we can help them feel happy all or most of the time or that they shouldn't have to feel sad or anxious. Understanding that educating these patients on what we can actually do and that negative feelings are not only normal but healthy and important is something I feel many outpatient psychiatrists rarely talk about. Especially those doing the 15 minute med-check appointments.

I have conversations about this pretty regularly. "So we do actually have a medication that can just make you feel good all the time if you take it really consistently. It's called heroin. It turns out to have some downsides."

 

[Celexa]

I have conversations about this pretty regularly. "So we do actually have a medication that can just make you feel good all the time if you take it really consistently. It's called heroin. It turns out to have some downsides."

Ha. Yes. My version is something like "my goal is for you to be able to live life without your mental health being major barrier. That means being able to access and experience the range of positive and negative emotions that are part of being alive". There's a reason I say "well" and not "happy".

Recently on the consult service a patient said he needed to stay in the hospital "until I don't have anxiety". = psychoed on unrealistic expectations and discharge.

But I don't run into that issue nearly as much outpatient. Obviously very variable in terms of type of clinic. The flip side and recurring motivation behind this line of teaching are the number of patients we see on the consult service whose outpatient providers say they have been 'stable and doing well' when they were objectively no such thing. Yes patients aren't always reliable reporters but looking back at notes it is often clear the provider never really dug into the thing and the patient plateued at 'better than the worst I've been'. The consult service is also often the first time residents see high functioning psychiatric outpatients (bc they're admitted for medical reasons) and they will come tell me the patisnt is fine bc they look dramatically better than the inpt psych patients do.... But that doesn't mean there's nothing we can help with.

 

[Stagg737]

I have conversations about this pretty regularly. "So we do actually have a medication that can just make you feel good all the time if you take it really consistently. It's called heroin. It turns out to have some downsides."

Ha. Yes. My version is something like "my goal is for you to be able to live life without your mental health being major barrier. That means being able to access and experience the range of positive and negative emotions that are part of being alive".

Mine is a bit more cynical. A lot of patients just want to numb their negative emotions and I let them know that I'm a psychiatrist, not an anesthesiologist.

My more serious discussions are in regards to what pathological vs normal anxiety and depression are and that my goal with them is not to "fix their feelings" but help them manage their emotions and function better. Especially when patients have major stressors in their lives. It's sometimes important to remind residents that our meds aren't going to fix a patient's homelessness or poverty or abusive relationship that them feeling down or anxious due to that stress is normal.

 

[comp1]

Ideally the goal of outpatient should be to make the person well enough to discharge just as much as inpatient. I'm not sure I've ever met anyone who was "well" in the Platonic Ideal sense of the word. My own system has immense trouble with psychiatry attendings holding on to easy and stable patients with death grips for all eternity. PCPs need them back or you won't have space for the patients you haven't even met yet who need your care. Admittedly, this is kind of complex, very systems driven, and most attendings haven't mastered outpatient discharges (other than for problematic patients) because there is often a financial disincentive to do so.

 

[clausewitz2]

Ideally the goal of outpatient should be to make the person well enough to discharge just as much as inpatient. I'm not sure I've ever met anyone who was "well" in the Platonic Ideal sense of the word. My own system has immense trouble with psychiatry attendings holding on to easy and stable patients with death grips for all eternity. PCPs need them back or you won't have space for the patients you haven't even met yet who need your care. Admittedly, this is kind of complex, very systems driven, and most attendings haven't mastered outpatient discharges (other than for problematic patients) because there is often a financial disincentive to do so.

That's fine when it can happen but there are a lot of outpatients who end up so doing well on medications their PCP won't touch with a ten foot pole. These people will probably need a steady outpatient psychiatrist long-term.

 

[Stagg737]

That's fine when it can happen but there are a lot of outpatients who end up so doing well on medications their PCP won't touch with a ten foot pole. These people will probably need a steady outpatient psychiatrist long-term.

Sure, but this is more of a problem with those PCPs not meeting basic standards of care/knowledge than anything. Yes, there are plenty of psych patients who should stick with a psychiatrist long-term d/t SMI or being on certain meds that really should be managed by a specialist. However, most psych patients don't have SMI/SPMI and should be able to return to a PCP at some point.

 

[comp1]

It's definitely a two way road, but if you aren't changing meds and are only seeing the patient every 3-6 months, it's time to go back to the PCP even if they're on three different meds or an adjunctive antipsychotic or whatever weird barrier the PCP tries to throw up. Good systems will facilitate this, smooth it out and prohibit inappropriate barriers. It helps no one to have SMI patients out there without access because a PCP is scared of refilling stimulants. Of course this is a thread about resident education, so I guess what you can do is model discharging patients back to PCPs regularly even if that means having a full on supportive psychotherapy session with said PCP. I get that this is still very much an issue within academic centers, but it should not be. You gotta fix it in academia so there's some hope for private practices where the financial incentives are horribly perverse.

 

[clausewitz2]

It's definitely a two way road, but if you aren't changing meds and are only seeing the patient every 3-6 months, it's time to go back to the PCP even if they're on three different meds or an adjunctive antipsychotic or whatever weird barrier the PCP tries to throw up. Good systems will facilitate this, smooth it out and prohibit inappropriate barriers. It helps no one to have SMI patients out there without access because a PCP is scared of refilling stimulants. Of course this is a thread about resident education, so I guess what you can do is model discharging patients back to PCPs regularly even if that means having a full on supportive psychotherapy session with said PCP. I get that this is still very much an issue within academic centers, but it should not be. You gotta fix it in academia so there's some hope for private practices where the financial incentives are horribly perverse.

I don't agree about the "not changing meds means not doing anything' but yes if you see someone every three months or more, they definitely need to be sent back if at all possible.

 

[Jules A]

It helps no one to have SMI patients out there without access because a PCP is scared of refilling stimulants.

Totally agree but doubt they are passing on the adult stimulant patients out of fear. 😉

 

[aim-agm]

I'd add that you need to have boundaries with systems as well as with patients. If the PCPs in your system won't take back suitable patients, then that is the system's problem, not yours. It is the system's responsibility to make sure that new patients can be seen, not yours.

On a clinical side, sleep and its treatment is very important outpatient not just because of how common a complaint insomnia is, but because with patients that have a lot going on it is a good idea to start with sleep - usually pretty quick and easy to address and results in significant reduction of distress and functional improvements (e.g. a well rested brain can deal with things a lot better).

Also, discussing that in outpatient there are many different valid styles and approaches and part of their professional journey will be discovering and developing theirs. This includes how much they use psychotherapy. This includes which medications they tend to use (both which classes and which medications within the class), how they use them (e.g. how quickly do they titrate SRIs), and even what their goals with medications are. This can include how they use interventions (e.g. ECT, TMS). And so on and so forth.

 

[aim-agm]

I have conversations about this pretty regularly. "So we do actually have a medication that can just make you feel good all the time if you take it really consistently. It's called heroin. It turns out to have some downsides."

"If you want to feel good, use heroin. If you want to feel bad, keep using heroin. If you want to feel awful, stop using heroin."

Also, trivia: Heroin should be capitalized, because it is the brand name for diacetylmorphine (approved in UK, not in US).

 

[clausewitz2]

"If you want to feel good, use heroin. If you want to feel bad, keep using heroin. If you want to feel awful, stop using heroin."

Also, trivia: Heroin should be capitalized, because it is the brand name for diacetylmorphine (approved in UK, not in US).

Sure, I'll make sure to do that, right after I take this Escalator back up to the Laundromat where I left my Aspirin and the Videotape of my Hovercraft.

 

[calvnandhobbs68]

Totally agree but doubt they are passing on the adult stimulant patients out of fear. 😉

Yeah there was a facebook post recently where a lot of PCPs chimed in and basically said they don't want to have to deal with stimulants or any other controlled meds and "that's why they're seeing a specialist"....I mean whatever.

I feel for the PCPs but then you can't turn around and complain about how you can never get people in to see psych.

 

[FlowRate]

Residents JUST starting outpatient? I'll assume they've learned a lot of necessary interruption/interviewing skills for now.

Who to go to for help, how to find or contact them, how timely to expect that help, what to do if your primary designated helper isn't available.

Fineries of your state's laws and institution's GC's interpretations of those laws when it comes to initiating MH holds in an outpatient setting.

Timeliness and capabilities of designated security, panic button, organizing room for safety (as much as possible.)

Support staff (although most residencies don't get much of that) and their limits and capabilities. Processes and clinic/institution/residency guidelines for any requested paperwork. Prior authorizations.

In other words, "how to manage the worst-case scenario patient who shows up in the outpatient setting and demands short term disability, threatens suicide and violence to get the short term disability, has an actual history of suicide attempts and violence, and probably actually needs the STD paperwork done, along with a hold (state dependent), because they're actually having a mixed manic episode and aren't just an A-hole."