It is bad, and it is getting worse

[SmallBird]

The misalignment between what we are trained to do and what we are asked to do in clinical practice is burning me out and it seems to be getting worse. I was manically happy during my residency training, where I learned a range of skills and acquired broad knowledge that allowed me to create detailed formulations to explain the behavior of my patients, and then suggest and implement precise tools that could help with goals ranging from symptom relief to functional recovery. As someone who has always enjoyed inpatient work, I find that increasingly my task has almost nothing to do with that skillset, and that a comprehensive approach is not only challenging, but in someways counterproductive and disincentivized. Starting with diagnosis, this has become democratized to the point where patients have filed complaints when providers have not supported their self-identification with labels like ASD, OCD, and DID. I have now had two pseudo seizure patients be intubated because the hospital has liability concerns when they have more dramatic presentations and are unwilling to get behind the idea that the patients symptoms are psychogenic. I used to write a formulation in my notes but realized that nobody on the treatment team was remotely modifying their approach based on the specific features of the patient anyway. And as it relates to treatment, I am encountering a significant increase in resistance to any treatment approach that prioritizes longer term recovery (such as exposures) over short term symptom relief, and a great deal more overt abuse from non-psychotic patients who are more deliberately rude during interviews than I feel has been the case before. I don't really know what the point of most of my work is and the doctors in my system who do the best financially and emotionally are the one's who seem to completely disengage and simply go through the motions of making conservative dose increases during each encounter. Some of our on-call functions have been replaced by PA's who make a number of mistakes but as there is no real mechanism for tracking quality it has sort of just become accepted. I am lucky to be happy in my personal life but am thinking of going back to school after a few more years of saving up money. I am surprised to be at this point after years of naive optimism.

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[Celexa]

You're all inpatient? Inpatient psychiatry has absorbed and been shaped by all of the worst forces in American healthcare. It has been literally gutted and starved and then Covid landed what will probably be the death blow by triggering an exodus of most of the few good inpatient psych nurses left. If inpatient psych was all there was, I would quit psychiatry tomorrow.

Why not just change settings?

 

[claypigeon]

This sounds par for the course for big box consumer first medicine. You’re never going to be the richest or most well liked doc if you practice good medicine. But you don’t have to be poor or hated.

PNES patient being given prn benzos after neuro has cleared them? No reason you can’t stop the benzo and document in the note your recommendation against intubation and the subsequent risk of hospital acquired infection.

OC spectrum patient being given unhealthy levels of reassurance or pharmacologic escapism? No reason you can’t stop the benzo and document in the note your recommendation against further instilling unhealthy reassurance seeking behaviors.

Abusive patient requesting you to diagnose them with a self identified label or wanting controlled substances that aren’t indicated? No reason you can’t stop the benzo and recommend they seek a second opinion elsewhere.

 

[Bartelby]

I agree with Celexa. Inpatient is very focused on risk assessment, brief intervention, and efficiency. In outpatient settings you can definitely do exposures, make treatment plans informed by a thoughtful formulation, and take plenty of time to help patients make genuine changes to improve their lives. You can also discharge the abusive ones (and the intensity of abuse is far lower v inpatient).

A setting switch seems way less drastic than a career change, and might be an effective fix.

 

[Sushirolls]

Big Box Shops strike again.

Outpatient will be a source of respite for these entropy forces.

However, even in outpatient they are still at work and the entropy is still nipping away, just more slowly. I see ASD self diagnosis, or ADHD self diagnosis, cannabis is the cure all, perpetuation of bipolar, etc. I've gotten to the point of bluntly telling patients, no, you don't have ADHD, these are the things we need to focus on. But if you want there are numerous ARNPs around you can call up say, you have ADHD, and will likely walk out with an adderall Rx the same day. I lose patients for these assessments and telling all patients I will taper off or stop benzos. The solace I have is I practice medicine the way I would want for my own family. I'm not making bank, but I have not burned out enough yet to check out. Positively my practice is growing steadily so greater money might flow eventually.

[my long rant of society, politics shaping the why healthcare entropy is happening before our eyes; triggers some who disagree with political spin; thread derails]

Still, I have my dream on my career change, and I hear the rhythmic clunking of the tractor diesel engine, the rough jostling of a rudimentary cushioned seat as I slowly trek across the field. The ever present perfume of cow manure. My future cologne of sweat, oil, and soil. Etc. "Green acres is the place to be..."

Good luck @SmallBird

 

[Sushirolls]

Alternatively, if you still have an modicum of inpatient purity hope left... consider this.

Critical care access hospitals are 25 beds. I learned from the CEO of one of these places, they can expand, and not lose their CCAH status, by have 10 extra beds devoted to psychiatry, or even 10 more beds for PM&R type rehab.

You could approach one of those places and say you are willing to commit to them for XYZ, and you want to run as med director there and build up the IP unit, do C/L [LOL, 1 patient if that per day] and perhaps a pinch of OP. Essentially be the Psychiatrist and spend a few years trying to recruit another Psych to assist you with coverage. A lot easier to infect a whole department with professionalism, optimism, and quality work ethos when you are the one running it, and build it up from the start. And if a hospital spends the effort to build up a unit and the % capital investment for such a unit relative to the rest of of the hospital... odds are you'll have a positive working relationship that leads to quality work environment. Might not be optimized income to work - but your zeal still gets to run free.

 

[Crayola227]

This sounds par for the course for big box consumer first medicine. You’re never going to be the richest or most well liked doc if you practice good medicine. But you don’t have to be poor or hated.

PNES patient being given prn benzos after neuro has cleared them? No reason you can’t stop the benzo and document in the note your recommendation against intubation and the subsequent risk of hospital acquired infection.

OC spectrum patient being given unhealthy levels of reassurance or pharmacologic escapism? No reason you can’t stop the benzo and document in the note your recommendation against further instilling unhealthy reassurance seeking behaviors.

Abusive patient requesting you to diagnose them with a self identified label or wanting controlled substances that aren’t indicated? No reason you can’t stop the benzo and recommend they seek a second opinion elsewhere.

Yes, however this doesn't address effectively what the OP is lamenting, which is a system that has gone from being based in collaboration between the effective parts (patient, physician, healthcare team) to one that is literally just based in conflict. Your suggestions for managing the conflicts are sound, but doesn't get to the heart of the complaint itself. I don't know what real fix there is beyond private practice and choosing your patients however.

 

[SmallBird]

Alternatively, if you still have an modicum of inpatient purity hope left... consider this.

Critical care access hospitals are 25 beds. I learned from the CEO of one of these places, they can expand, and not lose their CCAH status, by have 10 extra beds devoted to psychiatry, or even 10 more beds for PM&R type rehab.

You could approach one of those places and say you are willing to commit to them for XYZ, and you want to run as med director there and build up the IP unit, do C/L [LOL, 1 patient if that per day] and perhaps a pinch of OP. Essentially be the Psychiatrist and spend a few years trying to recruit another Psych to assist you with coverage.

I felt good about my work when I was the medical director but it was so much work keeping different parts of the system aligned. We got seclusions way down, our outcomes improved dramatically, but it required inserting myself into every part of the process. When I took a leave for a deployment everything went to sh$t as I was unable to translate my own approach into a self-sustaining system. That isn't a humble brag, it really was a failure, as I couldn't keep it up more than a year. But I do agree that this is something that could be done and my own experience doesn't imply a more general problem.

 

[Merovinge]

I strongly recommend looking into PHP/IOP/RTC LoC work. You will have similar acuity to IP minus the frank mania/psychosis but care for people over a time course that real change can occur. Good formulation and collaboration actively make a difference in people's lives. Some of this industry is still doctor led and has way less red tape (particularly at PHP/IOP levels) than IP, so the admin power is dramatically less.

 

[comp1]

Sad to see the doom and gloom comments about inpatient work. Believe me, it's still great at many places with many, many great RNs. In regards to the OP in specific, I would second the above comment on PHP since I think the way the OP is conceptualizing inpatient work is now really delegated to PHPs. We don't keep patients for weeks or months if we can avoid it inpatient. It's about minimal stabilization and get out, as quickly as you can do it safely. It's not about developing long term coping skills or even really the medium length necessary skills to stay out of the hospital, that's done by the PHP. Same with meds, you're almost certainly not going to get to full therapeutic levels during a brief inpatient stay. This is not a bad thing as an inpatient setting can sometimes not be the most therapeutic environment to work on those skills. All of that said, the OP said they were "manically happy" during residency. Maybe they need to go into academics or (to reduce the paycut) at least work at an academic affiliated site with some residents and med students.

 

[Stagg737]

Agree with comp1, the type of inpatient work OP is describing seems reserved to unit at ivory towers (which I believe OP graduated from) and the expectation of starting long-term work is something I haven't seen and have often been explicitly taught NOT to do (don't acutely open Pandora's box if you can't put everything back). This may be better at state or forensic hospitals where you know the patient is going to be there a while, but most inpatient units today are for acute stabilization and the type of work OP describes doesn't really seem appropriate for many of those patients.

I can sympathize with a lot of the complaints, but as others said it sounds like OP would do much better in another setting.

 

[Merovinge]

Sad to see the doom and gloom comments about inpatients. Believe me, it's still great at many places with many, many great RNs. In regards to the OP in specific, I would second the above comment on PHP since I think the way the OP is conceptualizing inpatient work is now really delegated to PHPs. We don't keep patients for weeks or months if we can avoid it inpatient. It's about minimal stabilization and get out, as quickly as you can do it safely. It's not about developing long term coping skills or even really the medium length necessary skills to stay out of the hospital, that's done by the PHP. Same with meds, you're almost certainly not going to get to full therapeutic levels during a brief inpatient stay. This is not a bad thing as an inpatient setting can sometimes not be the most therapeutic environment to work on those skills. All of that said, the OP said they were "manically happy" during residency. Maybe they need to go into academics or (to reduce the paycut) at least work at an academic affiliated site with some residents and med students.

I think there's something to be said about the explosion of learning that occurs during residency. I wasn't quite manically happy, but I was very fulfilled during my training and the first few years of being an attending. As the learning has slowed down, it's just a different phase of my career and I do find it harder to keep up with the most recent literature which makes me a bit forlorn. I think even finding a system of collaboration with colleagues (I do a monthly Zoom lunch hour with several other attendings to spitball cases), finding new articles via our professional organizations, linked in, or anything else can help keep a portion of that curiosity/learning alive while still recognizing that we simply are not residents anymore and it won't ever be the same.

 

[Stagg737]

Conversely, I'm feeling pretty burnt out from the outpatient side of things. I only do 1 day of outpatient a week, but generally dread it and feel a lot "lighter" when that day is over for the rest of the week.

A large percentage of my patients don't really seem motivated to get better and just want the magic pill that will make their uncomfortable feelings go away. I do a lot of brief psychotherapeutic interventions, but even when I spend more time with patients on education, expectation management, and actual therapy, many of them still just want something so they don't have to feel their emotions which are often completely appropriate for their situation (my mom died and I don't want to feel sad, I'm getting divorced and my anxiety is high, my XYZ medical issues are getting worse and I'm overwhelmed). I try and incorporate a lot of ACT and CBT components and they seem to appreciate it during that appointment, but next time I see them it's like they retained nothing from previous encounters. Many of them are also already doing therapy and while I can't speak for all the therapists, I know one or two of them personally and they are excellent PhD level psychologists.

Even with all that, many of the patients just seem stuck and don't make progress, and it seems like they just don't want to. I have plenty of patients are great, but probably 1/4 to 1/3 of them are like I described above and just drain me. That's not even getting into any new consult I see which may be a total trainwreck or just an unnecessary consultation, dealing with patient messages, prescription hassles/pharmacy issues, .

I know plenty of people here talk about how much better outpatient is after residency, but I'm just not experiencing it. Maybe it's just the nature of the clinic (telehealth consult clinic to rural areas), but it's all the same things I hated about OP clinic in residency but in much smaller doses. As stressful as working in an ER can be, I find it so much less emotionally draining and less stressful than any of the outpatient clinics I've worked in.

Do any of the outpatient docs here struggle as much as I do with patients lacking motivation or failing to take responsibility for their own MH instead of just wanting the pill to numb their emotional distress?

 

[SmallBird]

Agree with comp1, the type of inpatient work OP is describing seems reserved to unit at ivory towers (which I believe OP graduated from) and the expectation of starting long-term work is something I haven't seen and have often been explicitly taught NOT to do (don't acutely open Pandora's box if you can't put everything back). This may be better at state or forensic hospitals where you know the patient is going to be there a while, but most inpatient units today are for acute stabilization and the type of work OP describes doesn't really seem appropriate for many of those patients.

I can sympathize with a lot of the complaints, but as others said it sounds like OP would do much better in another setting.

I guess I think that inpatient units can and should provide something that is fairly complex and comprehensive. I agree that some things are explicitly inappropriate, like opening up trauma narratives, but I believe that the inpatient stay should lead to a comprehensive assessment of why the person entered crisis across dimensions of biological treatment, personality and social factors, and then implement or arrange for the provision of treatment that is specifically responsive to those factors. For example, someone with a history of schizophrenia being readmitted should have a different treatment course based on whether the reason for crisis is thought to be a true failure of medication, or some weakness in their containment plan, or the worsening of chronic neurocognitive impairments, or perhaps just an adherence issue. I'm not expecting to do deep work, but at least hope that the acute stabilization be individualized and specific. By contrast, more common experiences are 1) patients who are reflexively switched to new medications simply because they are admitted; 2) patients who have a strong agenda to get some specific treatment or substance provided to them; 3) patients who are chronically unsupported in the community but are presented as having psychosis exacerbations in order to get admitted, and 4) patients for whom the entire concept of treatment goals and recovery just isn't of interest but because we continue to try and stake more territory for the field of mental health we for some reason have to tolerate dysfunctional interactions and allow them to access our services when it meets some type of need they have. I will admit it's not as bad as what I'm saying but I don't think the frustration is because of not understanding the role of inpatient.

 

[SmallBird]

Conversely, I'm feeling pretty burnt out from the outpatient side of things. I only do 1 day of outpatient a week, but generally dread it and feel a lot "lighter" when that day is over for the rest of the week.

A large percentage of my patients don't really seem motivated to get better and just want the magic pill that will make their uncomfortable feelings go away. I do a lot of brief psychotherapeutic interventions, but even when I spend more time with patients on education, expectation management, and actual therapy, many of them still just want something so they don't have to feel their emotions which are often completely appropriate for their situation (my mom died and I don't want to feel sad, I'm getting divorced and my anxiety is high, my XYZ medical issues are getting worse and I'm overwhelmed). I try and incorporate a lot of ACT and CBT components and they seem to appreciate it during that appointment, but next time I see them it's like they retained nothing from previous encounters. Many of them are also already doing therapy and while I can't speak for all the therapists, I know one or two of them personally and they are excellent PhD level psychologists.

Even with all that, many of the patients just seem stuck and don't make progress, and it seems like they just don't want to. I have plenty of patients are great, but probably 1/4 to 1/3 of them are like I described above and just drain me. That's not even getting into any new consult I see which may be a total trainwreck or just an unnecessary consultation, dealing with patient messages, prescription hassles/pharmacy issues, .

I know plenty of people here talk about how much better outpatient is after residency, but I'm just not experiencing it. Maybe it's just the nature of the clinic (telehealth consult clinic to rural areas), but it's all the same things I hated about OP clinic in residency but in much smaller doses. As stressful as working in an ER can be, I find it so much less emotionally draining and less stressful than any of the outpatient clinics I've worked in.

Do any of the outpatient docs here struggle as much as I do with patients lacking motivation or failing to take responsibility for their own MH instead of just wanting the pill to numb their emotional distress?

Thanks for sharing this. I am grateful for the responses that have made the good points that setting is important, and have had good experiences in other settings myself, and will likely make a change soon. But I haven't found outpatient to be immune to these challenges and agree with your experiences here.

 

[Celexa]

Thanks for sharing this. I am grateful for the responses that have made the good points that setting is important, and have had good experiences in other settings myself, and will likely make a change soon. But I haven't found outpatient to be immune to these challenges and agree with your experiences here.

You mentioned going back to school.... A fellowship is hella cheaper than a degree and opens up more routes back into academia if that would be more satisfying for you (definitely not necessary, but as I've discussed in other threads, it's helpful). Given how few fellowships fill you can often find positions even in the middle of the year, and some might be willing to be flexible with you to allow you to retain some attending income*. Worth a thought.

*I haven't specifically seen this done in psych, but ive seen it done by medicine attendings who for example did palliative fellowships and just took a bit longer to finish while still attending on general medicine.

 

[comp1]

Okay, the OP's view of inpatient care is beautiful and also not super realistic at most places. I now have a suspicion they would be disappointed in community PHP's too. Definitely go back to academics and it's going to need to be a university based hospital to see what you're describing. Even most community based residencies are going to fall short.

 

[G Sheb]

Sad to see the doom and gloom comments about inpatient work. Believe me, it's still great at many places with many, many great RNs. In regards to the OP in specific, I would second the above comment on PHP since I think the way the OP is conceptualizing inpatient work is now really delegated to PHPs. We don't keep patients for weeks or months if we can avoid it inpatient. It's about minimal stabilization and get out, as quickly as you can do it safely. It's not about developing long term coping skills or even really the medium length necessary skills to stay out of the hospital, that's done by the PHP. Same with meds, you're almost certainly not going to get to full therapeutic levels during a brief inpatient stay. This is not a bad thing as an inpatient setting can sometimes not be the most therapeutic environment to work on those skills. All of that said, the OP said they were "manically happy" during residency. Maybe they need to go into academics or (to reduce the paycut) at least work at an academic affiliated site with some residents and med students.

I vehemently disagree with this.
This IS a bad thing and not what 'treatment' actually means. In practice, patients get flooded with meds so they can be 'stabilized as quickly as possible', with poor coordination with outpatient providers, and they are sent a hot mess in the making where months, sometimes years of work, have to start all over again. It's like the opposite of what 'treatment' is.

Just because this is what is happening in many places, it does not mean at all it's what is appropriate.

Luckily this is not how inpatient psychiatry is practiced everywhere. I work in an academic place. Patients stay as long as they need to. 2, 3, 4 weeks or more. Whatever it takes to send an improved and stable patient, with careful attention to diagnosis, medication dose and discharge planning.

 

[PikminOC]

I vehemently disagree with this.
This IS a bad thing and not what 'treatment' actually means. In practice, patients get flooded with meds so they can be 'stabilized as quickly as possible', with poor coordination with outpatient providers, and they are sent a hot mess in the making where months, sometimes years of work, have to start all over again. It's like the opposite of what 'treatment' is.

Just because this is what is happening in many places, it does not mean at all it's what is appropriate.

Luckily this is not how inpatient psychiatry is practiced everywhere. I work in an academic place. Patients stay as long as they need to. 2, 3, 4 weeks or more. Whatever it takes to send an improved and stable patient, with careful attention to diagnosis, medication dose and discharge planning.

Yes ivory tower care. Not the real world

 

[G Sheb]

Yes ivory tower care. Not the real world

Good care is good care and bad care is bad care. These "academic places" are caring for some of the most disadvtanged people in our society and and in fairly large numbers>
Whether it happens at an Ivory Tower or wherever is irrelevant.
I find this kind of justification for bad practice pretty lazy. We all know that hospital admin don't give a hoot about patients. We shouldn't be spreading that mentality because it makes it easier to live with a bad job.

 

[dl2dp2]

Thanks for sharing this. I am grateful for the responses that have made the good points that setting is important, and have had good experiences in other settings myself, and will likely make a change soon. But I haven't found outpatient to be immune to these challenges and agree with your experiences here.

Outpatient [cash] private practice with 50% psychotherapy component.

Now that being said, in therapy you obviously still have people who are poorly motivated and don't make progress, but the hassle-free frame makes it easier to actually focus on the clinical process rather than externalities.

 

[Sushirolls]

Good care is good care and bad care is bad care. These "academic places" are caring for some of the most disadvtanged people in our society and and in fairly large numbers>
Whether it happens at an Ivory Tower or wherever is irrelevant.
I find this kind of justification for bad practice pretty lazy. We all know that hospital admin don't give a hoot about patients. We shouldn't be spreading that mentality because it makes it easier to live with a bad job.

Academic places are evening shutting down units. I recall an article of Univ Washington recently, I think another on East Coast and one in Midwest that was axing units.
Not all academic places can burn the benjamins.

 

[romanticscience]

I've found that the reason I'm happy in my job is that I control the frame of the treatment. Outside of solo PP, you have to share that frame with parties who have different values/incentives. I'm not necessarily doing psychotherapy with everyone, but at the very least, patients have to buy into a real patient-doctor relationship with at least some sort of personal responsibility.

In a motivational spirit:
You don't like your diagnosis. Reflect, Affirm, Discharge.
You don't like your treatment. Reflect, Affirm, Discharge.
You want to abuse my system (e.g., not pay, not show, play with your meds, lie). Reflect, Affirm, Discharge.

You offer people a highly valuable experience with a doctor who wants to have a relationship with them. If they don't like that, enjoy the big box shop care . Many people won't admit it, but they actually want a doctor who doesn't care and just prescribes them what they ask for. Sad to hear you have to take care of some of them.

 

[randomdoc1]

I fully agree with posts talking about finding an environment that works for you. That's a lot of what this is about. It feels good to be able to help the people who actually want real help versus perpetuate being infantilized. There is a following out there, of people who actually want to do the tried and true ways, not resort to recreational substances, who don't want to be drug seeking and truly want to live healthy lives. It's a matter of finding them and the environment that will support your approach. But most places -- money makes the world go round. Even medical settings will just make a straight shot to the most profitable route and that often results in perpetuating unhealthy lifestyles. There's little to no incentive to effective primary care and mitigating things like vascular risk (DM control, smoking cessation, diet in fruits and vegetables) but boy does insurance pay big bucks for the vascular surgeries. How can we expect the psychiatry to be any different? But we as providers can make the choice of what route we want to choose. And yes, it's possible to be evidence based AND make a nice living.

 

[Celexa]

Academic places are evening shutting down units. I recall an article of Univ Washington recently, I think another on East Coast and one in Midwest that was axing units.
Not all academic places can burn the benjamins.

My bitter comment above comes entirely from academic experiences. Or rather, from seeing exactly what I described in academic units and knowing from interacting with other institions that anywhere else was even worse. In some ways being in academia just made it more painful, trying to do your best and knowing the system has kneecapped you. And yes, you are correct that academic places have been closing units.

Ironically, I get to practice some of the best inpatient psychiatry of my life on CL. I don't particularly enjoy seeing patients who are medically ready to go since by definition if they are ready to leave they are usually no longer an interesting CL case, but at the same time that limbo means no insurance is looking over *my* shoulder. Until a bed is available (which can be a long time), the only person whose opinion about discharge timing matters is mine, and there's no utilization review telling me there needs to be a med change every day to justify ongoing admission. I send a lot of people home who get better while waiting for an inpatient psych bed on way less medication than they would have been on if they'd gotten one.

 

[Stagg737]

Luckily this is not how inpatient psychiatry is practiced everywhere. I work in an academic place. Patients stay as long as they need to. 2, 3, 4 weeks or more.

It's not everywhere but it is the norm for the vast majority of "acute" inpatient hospitals. Your patients can stay as long as they need BECAUSE it is an academic hospital. If you can't justify acute stabilization to CMS, they stop paying. The only other places I've seen that are 1 VA unit I worked on where the attending had been there so long he could basically do whatever he wanted and the feds had minimal to no recourse and a forensic unit where patients were court-ordered to be there. Yes, plenty of patients would benefit from more time, but it's also on the psychiatrist and others directly involved in treatment to make the time they are on the unit worthwhile.

I'm not expecting to do deep work, but at least hope that the acute stabilization be individualized and specific. By contrast, more common experiences are 1) patients who are reflexively switched to new medications simply because they are admitted; 2) patients who have a strong agenda to get some specific treatment or substance provided to them; 3) patients who are chronically unsupported in the community but are presented as having psychosis exacerbations in order to get admitted, and 4) patients for whom the entire concept of treatment goals and recovery just isn't of interest but because we continue to try and stake more territory for the field of mental health we for some reason have to tolerate dysfunctional interactions and allow them to access our services when it meets some type of need they have.

That's fair and I think that's more on the psychiatrist to practice good medicine and not just burn and churn. Situation 1 is completely within control of the psychiatrist, 2 is just an unfortunate reality of our field in all settings, 3 is a completely legitimate concern and more of commentary of lack of appropriate outpatient resources than any shortcoming of an inpatient unit, 4 is more of a commentary on society's expectations of treating patient with psych diagnoses with a one-size-fits-all mentality rather than individualized care which is again something that inpatient practice is only a reflection of. For the last, I get criticized by patients and families regularly in our ER when I discharge them because how dare I not bend over backwards to help them.

A lot of the above is dependent on the inpatient docs, how they want to practice, which patients they chose to accept, etc. Again, I completely understand the frustrations, but these mostly sound like general statements that can be within our control as psychiatrists and teams.

 

[Marasmus1]

Conversely, I'm feeling pretty burnt out from the outpatient side of things. I only do 1 day of outpatient a week, but generally dread it and feel a lot "lighter" when that day is over for the rest of the week.

A large percentage of my patients don't really seem motivated to get better and just want the magic pill that will make their uncomfortable feelings go away. I do a lot of brief psychotherapeutic interventions, but even when I spend more time with patients on education, expectation management, and actual therapy, many of them still just want something so they don't have to feel their emotions which are often completely appropriate for their situation (my mom died and I don't want to feel sad, I'm getting divorced and my anxiety is high, my XYZ medical issues are getting worse and I'm overwhelmed). I try and incorporate a lot of ACT and CBT components and they seem to appreciate it during that appointment, but next time I see them it's like they retained nothing from previous encounters. Many of them are also already doing therapy and while I can't speak for all the therapists, I know one or two of them personally and they are excellent PhD level psychologists.

Even with all that, many of the patients just seem stuck and don't make progress, and it seems like they just don't want to. I have plenty of patients are great, but probably 1/4 to 1/3 of them are like I described above and just drain me. That's not even getting into any new consult I see which may be a total trainwreck or just an unnecessary consultation, dealing with patient messages, prescription hassles/pharmacy issues, .

I know plenty of people here talk about how much better outpatient is after residency, but I'm just not experiencing it. Maybe it's just the nature of the clinic (telehealth consult clinic to rural areas), but it's all the same things I hated about OP clinic in residency but in much smaller doses. As stressful as working in an ER can be, I find it so much less emotionally draining and less stressful than any of the outpatient clinics I've worked in.

Do any of the outpatient docs here struggle as much as I do with patients lacking motivation or failing to take responsibility for their own MH instead of just wanting the pill to numb their emotional distress?

Are you an adult psychiatrist? My experience has been quite different with children and adolescents. Give me supportive/loving parents and there would be only handful of kids who would not be improving with treatment over time.

 

[Stagg737]

Are you an adult psychiatrist? My experience has been quite different with children and adolescents. Give me supportive/loving parents and there would be only handful of kids who would not be improving with treatment over time.

I am. Mostly work in the ER, but have an outpatient consultation clinic which is telehealth only. Once upon a time I wanted to do CAP, but then I realized I enjoyed working with one patient at a time and not dealing with what you described for 75% of patients or more. Unfortunately, this has been shockingly prevalent for many adults I deal with too.

 

[SmallBird]

It's not everywhere but it is the norm for the vast majority of "acute" inpatient hospitals. Your patients can stay as long as they need BECAUSE it is an academic hospital. If you can't justify acute stabilization to CMS, they stop paying. The only other places I've seen that are 1 VA unit I worked on where the attending had been there so long he could basically do whatever he wanted and the feds had minimal to no recourse and a forensic unit where patients were court-ordered to be there. Yes, plenty of patients would benefit from more time, but it's also on the psychiatrist and others directly involved in treatment to make the time they are on the unit worthwhile.


That's fair and I think that's more on the psychiatrist to practice good medicine and not just burn and churn. Situation 1 is completely within control of the psychiatrist, 2 is just an unfortunate reality of our field in all settings, 3 is a completely legitimate concern and more of commentary of lack of appropriate outpatient resources than any shortcoming of an inpatient unit, 4 is more of a commentary on society's expectations of treating patient with psych diagnoses with a one-size-fits-all mentality rather than individualized care which is again something that inpatient practice is only a reflection of. For the last, I get criticized by patients and families regularly in our ER when I discharge them because how dare I not bend over backwards to help them.

A lot of the above is dependent on the inpatient docs, how they want to practice, which patients they chose to accept, etc. Again, I completely understand the frustrations, but these mostly sound like general statements that can be within our control as psychiatrists and teams.

I think I wrote a similar post just a few years ago, and agree that one should always do the best you a with whatever is under your control. More recently, I have found that the experience of trying to practice in a way I feel good about is a source of burnout, as it feels like swimming upstream within the broader treatment context. Recently I was working with a patient detoxing from methamphetamines, and we were discussing a choice of medication that could perhaps take the edge of those most difficult moments when he felt like turning to illicit substances were essential, and he abruptly interrupted the discussion to say 'Why do you care so much? Just let me go home or sleep like the other doctors." Not to make too much of an anecdote, but it can be difficult to sustain an approach when you are working in isolation, and handing off cases to people who have no interest in your approach, and practice within a system that prioritizes metrics unrelated to the core of the work being done.

 

[Stagg737]

I think I wrote a similar post just a few years ago, and agree that one should always do the best you a with whatever is under your control. More recently, I have found that the experience of trying to practice in a way I feel good about is a source of burnout, as it feels like swimming upstream within the broader treatment context. Recently I was working with a patient detoxing from methamphetamines, and we were discussing a choice of medication that could perhaps take the edge of those most difficult moments when he felt like turning to illicit substances were essential, and he abruptly interrupted the discussion to say 'Why do you care so much? Just let me go home or sleep like the other doctors." Not to make too much of an anecdote, but it can be difficult to sustain an approach when you are working in isolation, and handing off cases to people who have no interest in your approach, and practice within a system that prioritizes metrics unrelated to the core of the work being done.

That sounds like more of a problem regarding our patient populations and less about the system, though they're mostly just reflections of each other imo.

I think for me, the reason I don't mind inpatient or C/L as much is because when I get a patient like that it's much easier to identify and lay out hard boundaries when they don't want to take ownership of their problems. I'm less invested in the relationship and it's easier for me to compartmentalize what I can and can't do for them and where I should place my energy.

With outpatient, I feel like it's more subtle and may not be obvious until you've been working with them for a while. There's more of a feeling out period when you're trying to really dig into what's going on and it's much more effort to peel back the layers. Then when they've failed several meds we find out that they're just not putting in the work on their end or they're not really motivated to get better or they just don't really want to get better at all, which is more of a blow to my morale since I feel like that effort was wasted and would have been used better elsewhere. It's certainly not the case with all of my outpatients, but in every clinic I've worked in it's felt like a significant enough amount (at least 25%) to the point where it just becomes draining.

 

[PikminOC]

Good care is good care and bad care is bad care. These "academic places" are caring for some of the most disadvtanged people in our society and and in fairly large numbers>
Whether it happens at an Ivory Tower or wherever is irrelevant.
I find this kind of justification for bad practice pretty lazy. We all know that hospital admin don't give a hoot about patients. We shouldn't be spreading that mentality because it makes it easier to live with a bad job.

I don't work ip. I have a pp outpatient only. I'm.referring to the fact that im regular hospitals the insurances won't cover the longer stays.

And as for academics they may have an indigent population, but they also have concierge care, which is not what their state and federal funding is for.

 

[annoyedpsychiatrist]

Yes, however this doesn't address effectively what the OP is lamenting, which is a system that has gone from being based in collaboration between the effective parts (patient, physician, healthcare team) to one that is literally just based in conflict. Your suggestions for managing the conflicts are sound, but doesn't get to the heart of the complaint itself. I don't know what real fix there is beyond private practice and choosing your patients however.

The interesting part that ive learned through all of these patients on crazy doses/medication regimens and getting idiotic treatments is 60% of the time its the fault of the prescriber, and 40% of the time its the fault of the patient. The 60% of people i can work with and help. I used to think "great another one" when id get adderall xr BID with ambien/xanax combination but some of these people are genuinely just trying to get help, and it was easier for the prescriber to give them a rx and be done with it rather than having an honest talk with them about expectations/safety/etc.

The problem is, the 40% they really burn you out. Realitsically my solution is that you cant save everyone, you can only save people that want to be saved and not people that want a medication vacation or validation party. Time is a limited resource and so many people need help, that actually want help and I want to focus on those people. In my ideal psych practice world, patients are given a chance with a reaosnable treatment plan, if they dont agree then we dont treat them. If they continually dont follow the agreement then they're fired. The harsh reality is we often cant just do this, depending on our work setting and these idiot business people/politicians have championed this bleeding heart philosophy of "the patient is always right". The patient is not always right, that is why we all have jobs. I was thinking about this the other day. I have patients coming to see me with major neurocog disorders, hypomania, psychosis, etc and then at the end of the visit they're given a rating form of how well i did. I literally had a psychotic patient fill out a 4 paragraph review that loosely tied in me, de santis, cruise ships, and various other things. Granted it was actually a good review since he gave me 5 stars so I guess ill take it? Its laughable that were asking people with impaired insight/reality testing to give objective reviews.

But i agree I hate tiktok with a passion. I dont like politics and im very moderate but the one thing I did like was when politicians were speaking of banning tik tok. I so hope that happens, i dream of that day.

We as providers are being hamstringed by people who have no business dictating healthcare and in turn this is negatively affecting patients through a system stupidly designed to "give them a voice"

 

[dl2dp2]

Not to make too much of an anecdote, but it can be difficult to sustain an approach when you are working in isolation, and handing off cases to people who have no interest in your approach, and practice within a system that prioritizes metrics unrelated to the core of the work being done.

You sound exactly like the type of doctor who would do *very well* in private practice and also get paid handsomely for providing care at a very high level of quality.

Keep in mind, one of the biggest characteristics that differentiate successful vs. unsuccessful private practice is turnover rates. People who pay you end up liking you because your service is better. And why is it better? Because you are doing more than the typical. This ends up generating a lot of demand, because is it really worth the time and effort to get treated with substandard care, even if it's "free"?

Of course, in order to move in that direction you have to psychologically get over the brainwashing from the institution that somehow providing high-quality care to a smaller number of people who can afford you is "unethical", and "against equity". You also have to really KNOW YOUR WORTH and manage your practice professionally and create a frame that makes sense.

 

[PsyDr]

IMO:

1) The problem is not democratic-ism. It's accepting every viewpoint as equally meritorious.
2) There is some social pressure to accept every viewpoint as equally valid.
3) However, #3 cannot be reconciled with your training.
4) If you accept the social pressure, of every opinion being equal, everyone is free to tell you how to practice. This is not dissimilar to some things Kohut wrote about.
5) Some of this conflict seems to be produced in the nuances. They are telling you what to do, without actually telling you what to do. If you tell them "No", you're a rude person. If you do what they are saying, you're a bad physician. But we all know the administration is not telling you, "the patient complained about the diagnosis". That's not the real communication. They are implicitly telling you to change your diagnosis.
6) As I see it, so long as you accept that social pressure, you're gonna have problems.

Or what do I know? I'm not there.

 

[smalltownpsych]

Conversely, I'm feeling pretty burnt out from the outpatient side of things. I only do 1 day of outpatient a week, but generally dread it and feel a lot "lighter" when that day is over for the rest of the week.

A large percentage of my patients don't really seem motivated to get better and just want the magic pill that will make their uncomfortable feelings go away. I do a lot of brief psychotherapeutic interventions, but even when I spend more time with patients on education, expectation management, and actual therapy, many of them still just want something so they don't have to feel their emotions which are often completely appropriate for their situation (my mom died and I don't want to feel sad, I'm getting divorced and my anxiety is high, my XYZ medical issues are getting worse and I'm overwhelmed). I try and incorporate a lot of ACT and CBT components and they seem to appreciate it during that appointment, but next time I see them it's like they retained nothing from previous encounters. Many of them are also already doing therapy and while I can't speak for all the therapists, I know one or two of them personally and they are excellent PhD level psychologists.

Even with all that, many of the patients just seem stuck and don't make progress, and it seems like they just don't want to. I have plenty of patients are great, but probably 1/4 to 1/3 of them are like I described above and just drain me. That's not even getting into any new consult I see which may be a total trainwreck or just an unnecessary consultation, dealing with patient messages, prescription hassles/pharmacy issues, .

I know plenty of people here talk about how much better outpatient is after residency, but I'm just not experiencing it. Maybe it's just the nature of the clinic (telehealth consult clinic to rural areas), but it's all the same things I hated about OP clinic in residency but in much smaller doses. As stressful as working in an ER can be, I find it so much less emotionally draining and less stressful than any of the outpatient clinics I've worked in.

Do any of the outpatient docs here struggle as much as I do with patients lacking motivation or failing to take responsibility for their own MH instead of just wanting the pill to numb their emotional distress?

I was just talking to my office admin about this yesterday. When I was a working an outpatient gig where I took all insurances including medicaid, I experienced the unmotivated patients quite a bit. In my current cash only setup, not so much. I saw twice as many patients and half were of the unmotivated type, now I see half as much. I am still making a little less but with a couple more IOP patients, including the one starting today, that metric will shift. Of course, that time I was spending on unmotivated patients has shifted to administrative tasks, but that is a lot less burnouty from my perspective.

 

[Bartelby]

Interestingly in outpatient treatment even the unmotivated patients don't bother me too much.

I perform an appropriate assessment. I educate them about what they should be doing to get better and document my advice. I prescribe appropriately, avoiding the harm that can come when providers start thinking magically about medications (oh, let's augment with an antipsychotic, and you know Depakote might help their mood lability, and I think a stimulant would really help their motivation!). I also do not participate in care I view as harmful. For example, if a patient wants a benzodiazepine and should not have it I explain why in a gentle but firm way. If they don't like it they can seek out other providers, there are plenty who will make it rain controlled substances.

I then provide gentle nudges from time to time about what they could be doing to improve their situation. I advise and they decide. If they decide to keep the status quo, take their Prozac, and do little to make progress then that's their call. I will be ready and waiting when and if they decide to approach treatment differently. I don't feel any need to discharge them from my panel, and I don't beat myself up about their choices. They are competent adults and need to make their own decisions in life and in treatment, and that remains my message to them.

 

[Celexa]

Of course, in order to move in that direction you have to psychologically get over the brainwashing from the institution that somehow providing high-quality care to a smaller number of people who can afford you is "unethical", and "against equity". You also have to really KNOW YOUR WORTH and manage your practice professionally and create a frame that makes sense.

AMEN. I judge bad doctors--I don't judge anyone for getting paid what they're worth.

That exact brainwashing is part of what has devalued our profession in the eyes of our colleagues and the wider culture. We aren't the only ones (looking at you, pediatrics) but when I do my underpaid academic work I am doing work that IS worth my private practice rate...and that's important to remember.

 

[Sushirolls]

Interestingly in outpatient treatment even the unmotivated patients don't bother me too much.

I perform an appropriate assessment. I educate them about what they should be doing to get better and document my advice. I prescribe appropriately, avoiding the harm that can come when providers start thinking magically about medications (oh, let's augment with an antipsychotic, and you know Depakote might help their mood lability, and I think a stimulant would really help their motivation!). I also do not participate in care I view as harmful. For example, if a patient wants a benzodiazepine and should not have it I explain why in a gentle but firm way. If they don't like it they can seek out other providers, there are plenty who will make it rain controlled substances.

I then provide gentle nudges from time to time about what they could be doing to improve their situation. I advise and they decide. If they decide to keep the status quo, take their Prozac, and do little to make progress then that's their call. I will be ready and waiting when and if they decide to approach treatment differently. I don't feel any need to discharge them from my panel, and I don't beat myself up about their choices. They are competent adults and need to make their own decisions in life and in treatment, and that remains my message to them.

This.
Meh. Don't want to change, I'll be here when ready, and keep nudging. Some people come around, some don't for a few years.
In some ways just really, really, slow inpatient happening before your eyes.

 

[Candidate2017]

Strong like ox, twice as smart.

How do people end up on the psych ward? They broke their mind. Mind broke, me fix. Not patient fix. Broke mind don't understand blah-blah words from my lips. Because broke. Psychotic, manic, or depressed. I saw, hammer and nail their fractured mind with antipsychotics, mood stabilizers, and SSRIs. Therapy do later, with someone else less skilled, less bling.

Starting with diagnosis, this has become democratized to the point where patients have filed complaints when providers have not supported their self-identification with labels like ASD, OCD, and DID.

Why patient awake and speak blah-blah ASD, OCD, DID? I stare blankly like ox, grunt and snort. Whatever transference or fart blows through their fractured mind, I don't know. Rule out personality disorder unspecified. But no hammer, saw, or nail. Therapy do later, with someone else less skilled, less bling. I go fix another mind.

OP, you smart. Too smart. Come down and play in the mud.

Do any of the outpatient docs here struggle as much as I do with patients lacking motivation or failing to take responsibility for their own MH instead of just wanting the pill to numb their emotional distress?

No.

 

[SmallBird]

There is a consistent agreement that being able to set the frame of treatment is important to having a good provider experience. Maybe I really should try private practice. I am just disappointed that there seems to be an ever increasing alignment between new social concepts of mental illness, systems expectations, and patient agendas which works against trying to create a frame that reflects the values I have as a provider.

 

[SmallBird]

Strong like ox, twice as smart.

How do people end up on the psych ward? They broke their mind. Mind broke, me fix. Not patient fix. Broke mind don't understand blah-blah words from my lips. Because broke. Psychotic, manic, or depressed. I saw, hammer and nail their fractured mind with antipsychotics, mood stabilizers, and SSRIs. Therapy do later, with someone else less skilled, less bling.



Why patient awake and speak blah-blah ASD, OCD, DID? I stare blankly like ox, grunt and snort. Whatever transference or fart blows through their fractured mind, I don't know. Rule out personality disorder unspecified. But no hammer, saw, or nail. Therapy do later, with someone else less skilled, less bling. I go fix another mind.

OP, you smart. Too smart. Come down and play in the mud.



No.

Too stupid more like This is like when people ask me which comedies I like and I'm with them for 'The Office' and 'Parks and Rec' but then when we get to 'Curb your enthusiasm' and 'Scrubs' I'm just lost.

 

[Merovinge]

Too stupid more like This is like when people ask me which comedies I like and I'm with them for 'The Office' and 'Parks and Rec' but then when we get to 'Curb your enthusiasm' and 'Scrubs' I'm just lost.

I'll admit I never got Curb either and was never over the moon for Seinfeld. That said Scrubs is a masterpiece (the core seasons, not whatever thing they did at the end). I needed a season to like the Office, scrubs is certainly worth making it through one was well.

 

[Stagg737]

Interestingly in outpatient treatment even the unmotivated patients don't bother me too much.

I perform an appropriate assessment. I educate them about what they should be doing to get better and document my advice. I prescribe appropriately, avoiding the harm that can come when providers start thinking magically about medications (oh, let's augment with an antipsychotic, and you know Depakote might help their mood lability, and I think a stimulant would really help their motivation!). I also do not participate in care I view as harmful. For example, if a patient wants a benzodiazepine and should not have it I explain why in a gentle but firm way. If they don't like it they can seek out other providers, there are plenty who will make it rain controlled substances.

I then provide gentle nudges from time to time about what they could be doing to improve their situation. I advise and they decide. If they decide to keep the status quo, take their Prozac, and do little to make progress then that's their call. I will be ready and waiting when and if they decide to approach treatment differently. I don't feel any need to discharge them from my panel, and I don't beat myself up about their choices. They are competent adults and need to make their own decisions in life and in treatment, and that remains my message to them.

This.
Meh. Don't want to change, I'll be here when ready, and keep nudging. Some people come around, some don't for a few years.
In some ways just really, really, slow inpatient happening before your eyes.

Maybe I'm just impatient or maybe it's just an ego thing, but if someone isn't motivated (not d/t severe depression, just generally unmotivated/dependent) or doesn't really want to get better, why waste all our time? I have better things to do than be a cheerleader or stern parental figure to a middle-aged whiner who is so averse to discomfort and basic effort that I could do a 5-minute med check and move along, and I'm sure many patients do too. Maybe if I were in more of a private practice setting like others have described where most patients are either motivated or legitimately sick at points where they're truly significantly anhedonic or depressed it would be different. I just find what you're both describing here so mundane and vapid. It just feels like death by a thousand papercuts...

 

[Bartelby]

Maybe I'm just impatient or maybe it's just an ego thing, but if someone isn't motivated (not d/t severe depression, just generally unmotivated/dependent) or doesn't really want to get better, why waste all our time? I have better things to do than be a cheerleader or stern parental figure to a middle-aged whiner who is so averse to discomfort and basic effort that I could do a 5-minute med check and move along, and I'm sure many patients do too. Maybe if I were in more of a private practice setting like others have described where most patients are either motivated or legitimately sick at points where they're truly significantly anhedonic or depressed it would be different. I just find what you're both describing here so mundane and vapid. It just feels like death by a thousand papercuts...

A few thoughts:

1- It's kind of like working in a substance use disorder treatment center. At times you have to meet the patient where they are. You may work with harm reduction, engage them in motivational interviewing, celebrate small wins, and be available when they decide to take next steps. Some of those patients will keep using heavily, but I think you still do a service working with those who are (at least initially) not motivated. It's a long-term numbers game, and you are still doing good.

2 - In a practical sense, it's hard to just tell a patient (in so many words) that they are wasting your time and then discharge them. And if you're not going to discharge them, finding the value in what you do and putting up appropriate emotional barriers (not feeling responsible for their choices) can help avoid burn out.

3 - If they genuinely don't have interest in treatment I would definitely have that conversation with them. They might choose to go and know that the door is open for re-intake if they change their mind. There's nothing wrong with that.

4 - This should not be most of your panel in the right outpatient setting. It's more a matter of dealing with a not insignificant subsection that you will get in most outpatient settings. The more motivated people racking up gains can help carry you through some of the more drudging encounters!

5 - Sometimes I think we just don't have the tools to adequately help patients. That can easily stir up feelings of helplessness and frustration in us, when obviously we want our patients to get better. I know there is a big difference in those who simply choose not to (for instance) go to recommended therapy, take recommended medications, or make recommended lifestyle changes versus those who (for instance) have schizophrenia and do their best but still have a severe symptom burden. Still, I have to monitor myself for some of that helplessness and frustration when dealing with a patient who just doesn't get better. I try to find compassion for what they are going through, and acknowledge that sometimes we just reach the limits of what we will realistically accomplish. I hope I still make such patients' lives better in some way, and the fact they keep coming back (when I'm not writing controlled substances or offering other obvious secondary gain) suggests I may be.

 

[G Sheb]

I was trained that it was the clinician's job to engage patients. If they are not engaging, then it's really your failure (not theirs), and you have to find what's missing and fix it. That's really our job. Of course one has to keep a frame as well, but some will go overboard and the frame ends up more about protecting themselves than providing treatment. It's a hard way to go about things, and some failures are inevitable, but I also think this makes the work more engaging and possibly more fun/interesting and you may end up feeling less burned out. I think many end up doing what they accuse patients of doing, i.e externalize and dump it all on something else.
If patients are not engaged in their treatment despite them showing up in your office, imo you have to figure out what you can do differently. Therapy training was extremely helpful for this. How to listen, connect, 'hold', 'validate'.. all of these can make a critical difference in patient engagement. Getting supervision can be extremely helpful as well.

 

[PsyDr]

I was trained that it was the clinician's job to engage patients. If they are not engaging, then it's really your failure (not theirs), and you have to find what's missing and fix it. That's really our job.

Is there any way to reconcile the idea of resistance with your clinical stance?

 

[G Sheb]

Is there any way to reconcile the idea of resistance with your clinical stance?

Of course. In a way, it's all about figuring out what's the resistance and addressing it.
But really, doing the basics in terms of validation, holding can go such a long way. Of course you can't do that the whole time and there will be bumps in the road, but in my experience getting skills in these made a big difference.

 

[erg923]

I was trained that it was the clinician's job to engage patients. If they are not engaging, then it's really your failure (not theirs), and you have to find what's missing and fix it. That's really our job.

Who "trained" you in that garbage? Don't work harder than your patient. You do not infantilize your patients.

 

[PsyDr]

Of course. In a way, it's all about figuring out what's the resistance and address it.

Typically resistance is overcome by interpreting the resistance. If I'm reading you correctly, it seems that instead of interpretation, you're advocating for the clinician to act differently. Is that right? If so, what's the approach, especially with medication?

 

[G Sheb]

Typically resistance is overcome by interpreting the resistance. If I'm reading you correctly, it seems that instead of interpretation, you're advocating for the clinician to act differently. Is that right? If so, what's the approach, especially with medication?

I think verbal interpretation and fleshing things out is one way of overcoming it. Sometimes it is necessary but not always. But the more important thing is being aware of it. Sometimes nonverbal communication will make a huge difference. My point try to see if there's something about you that's turning them off. How are you coming across? How are you addressing their issues? What else you are not payiing attention to? See what you can change. This is really case by case dependent. If it doesn't work out, try to learn from it. I think a lot of this means being aware of dynamics and unconscious stuff that is going on from both sides. You can do this with interventions with medications as well. If they are resistant to medications, why? Sometimes it just means you have to accept and go with it, and you will be surprised that x months down the road when they trust you more, they will start taking the medications.