What setting/subspecialty of psychiatry do you like/hate the most, and why?

[slowthai]

Inpatient, outpatient, emergency, CL, addiction, child, forensics, geri, neuropsych, neuromodulation, etc

I'm wondering the same for those that have psychotherapy as a large part of their practice

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[TheRightMedication]

I enjoy Intensive Outpatient programs the most - it's good, and for me more effective, to work with a team in that very direct way.

CL is my least favorite. I don't get much satisfaction from seeing delirium and dementia and being called to use medications with a number needed to harm that is close to the number of times I'll use it that day. I suppose diligence in monitoring for side effects is satisfying. For me in particular, consults for outpatient issues are especially frustrating as they delay me getting to my own outpatient private practice.

 

[slowthai]

I enjoy Intensive Outpatient programs the most - it's good, and for me more effective, to work with a team in that very direct way.

How common is this practice setting, especially compared to inpatient and outpatient?

 

[Candidate2017]

Many psychiatrists dabble in the multiple settings you've named. None are better than the other. They are just different, but have equal levels of suck. Except for child, which is whole other level of suck. You'll figure out which setting works best for you.

 

[reca]

I despise C/L. I would literally leave psychiatry entirely if I was forced to do C/L.

 

[Bartelby]

Like the most: general outpatient. The patients typically see you voluntarily, and hour for hour I feel like I'm doing more good than any other setting except maybe inpatient. You get to form real connections with patients and watch them recover. It is more cost-effective for society than any other setting, and high quality outpatient care can prevent escalation to other settings. You can do long-term work that is not realistic in most other settings. You can also discharge people from your panel if they truly aren't appropriate. Outpatient has its downsides but I think is overall the best setting.

Like the least: probably geriatric psychiatry on an advanced dementia unit. While rotating there it felt like many patients had behavioral problems that were just going to persist long-term, but I always felt pressure to find the magic pill that makes it all better (or more realistically pressure to slam the person with antipsychotics and other sedating medications). In fairness, it has been forever since I worked in such a setting so I may have an overly pessimistic recall of the situation.

 

[slowthai]

I despise C/L. I would literally leave psychiatry entirely if I was forced to do C/L.

Wow, why do you hate it?

 

[calvnandhobbs68]

Wow, why do you hate it?

Probably because like 90% of psychiatry consults are dumb and don't even need to be consults. YMMV though, some people love consults. I agree that if I was forced to do 100% CL I'd find another job or move but I'm all outpatient.

 

[TexasPhysician]

My least favorite are forensics and inpatient. Dealing with attorneys, contracts, and reports are boring. Inpatient SMI is fairly depressing for me.

I much prefer outpatient and addiction. Patients are typically motivated and improvement can be vast.

 

[allantois]

My least favorite are forensics and inpatient. Dealing with attorneys, contracts, and reports are boring. Inpatient SMI is fairly depressing for me.

I much prefer outpatient and addiction. Patients are typically motivated and improvement can be vast.

This is interesting because as we know both inpatient and SMI are full of addiction; I guess what we mean is patients with high SES and addiction do much better than those with SMI in inpatient care

Personally, I highly dislike any kind of addiction work

 

[nexus73]

Full time outpatient, patient after patient, five days a week. Forget it. I can do like 2-3 days clinic a week split up with other stuff interspersed. I don't know how people are seeing patients 8-5 M-F week after week. I can't handle being locked into a grid schedule.

Much prefer inpatient, consults on medicine and ED. My time is my own. When the work is done go home.

I've never done residential addictions or IOP, but if the work was more fluid and not bound to stay until 5pm that would be doable as well.

 

[surfguy84]

Full time outpatient, patient after patient, five days a week. Forget it. I can do like 2-3 days clinic a week split up with other stuff interspersed. I don't know how people are seeing patients 8-5 M-F week after week. I can't handle being locked into a grid schedule.

Much prefer inpatient, consults on medicine and ED. My time is my own. When the work is done go home.

I've never done residential addictions or IOP, but if the work was more fluid and not bound to stay until 5pm that would be doable as well.

I'm with you. I can do outpatient in small blocks. Hoping to do 3 x 5 hr days which I'd combine with inpatient.

 

[Merovinge]

How common is this practice setting, especially compared to inpatient and outpatient?

Increasingly common and very easy to get into these days. One of our local child fellowships had 3/4 take PHP/IOP jobs from their graduating class this last year for example. Outpatient will always be the most common (as it should be). Inpatient is relatively undesirable due to call, although many have gone to 7 on/7 off style to improve lifestyle as hospitals of all shapes/sizes have struggled to recruit inpatient psychiatrists for some time now.

 

[Dr. Pookie]

CL was the bane of my existence in residency. I'm not sure if it was because residents had zero power to refuse dumb consults (at least half) or because of the culture of "If there's no real psych problem, we'll find one." (verbatim what an attending told me), but every day on that service was miserable. Medicine/surgery/OB just used psych CL as glorified social workers and liability receptacles. Most patients weren't even told psych was coming to see them. I'm getting triggered just typing this out.

 

[surfguy84]

Increasingly common and very easy to get into these days. One of our local child fellowships had 3/4 take PHP/IOP jobs from their graduating class this last year for example. Outpatient will always be the most common (as it should be). Inpatient is relatively undesirable due to call, although many have gone to 7 on/7 off style to improve lifestyle as hospitals of all shapes/sizes have struggled to recruit inpatient psychiatrists for some time now.

What does an IOP job look like? The one hospital I discussed with it sounded like 2 days a week, seeing 12-15 patients per day. Wasn't any therapy, strictly talking about meds check in; i.e. 15-20 minute appts. Sounds like it was something you could come in and do and knock out in 3-4 hours. Is this what IOP jobs typically are?

 

[littlefred]

CL was the bane of my existence in residency. I'm not sure if it was because residents had zero power to refuse dumb consults (at least half) or because of the culture of "If there's no real psych problem, we'll find one." (verbatim what an attending told me), but every day on that service was miserable. Medicine/surgery/OB just used psych CL as glorified social workers and liability receptacles. Most patients weren't even told psych was coming to see them. I'm getting triggered just typing this out.

I have this capacity consult for you real quick, do you mind seeing the pt ASAP?

 

[Merovinge]

What does an IOP job look like? The one hospital I discussed with it sounded like 2 days a week, seeing 12-15 patients per day. Wasn't any therapy, strictly talking about meds check in; i.e. 15-20 minute appts. Sounds like it was something you could come in and do and knock out in 3-4 hours. Is this what IOP jobs typically are?

There are bad IOP/PHP's that are run by places without specialty in this care, bringing you in to widget care and have no other involvement so that they can maximize revenue with no regard to what's best for the patient.

Good programs will have MDs leading treatment teams like on an IP setting, possibly being in a group or two a week, staffing the patient's weekly, and offering places where treatment can be improved (beyond obviously meeting the patient every week). This is done much better on a full time basis where you are at the program everyday. Days are typically less busy than OP practice as you are expected to have time to talk to your team, outpatient psych/therapy/family etc.

 

[surfguy84]

There are bad IOP/PHP's that are run by places without specialty in this care, bringing you in to widget care and have no other involvement so that they can maximize revenue with no regard to what's best for the patient.

Good programs will have MDs leading treatment teams like on an IP setting, possibly being in a group or two a week, staffing the patient's weekly, and offering places where treatment can be improved (beyond obviously meeting the patient every week). This is done much better on a full time basis where you are at the program everyday. Days are typically less busy than OP practice as you are expected to have time to talk to your team, outpatient psych/therapy/family etc.

Out of curiosity - are places you described which are run by an MD actually better? I can envision an IOP that is run by a PhD and which uses an MD 1-2 days a week to meet with patients being a quality program. I feel like there are many non-MDs who provide significantly better therapy than myself - I can't imagine myself as the head of an IOP doing better than them.

 

[comp1]

I definitely prefer inpatient. I can see patients on my own schedule. Some patients need more time and some a lot less. Not everybody fits into a 30 minute/60 minute paradigm of outpatient. Also, the patients are generally not subtle inpatient. I found outpatient extremely boring while also somehow being more emotionally draining. Outpatient felt really lonely and it was harder to use "othering" as a coping skill. I do some CL and concur with others. Most consults are not appropriate and the problem is that your actual client is the medical service. I don't like treating physicians IOP sounds fine, I've never tried it. I have some some psych ED work and would probably like that a great deal. However, from a systems perspective, I prefer that psych ED's are attached to inpatient units and inpatient physicians admit their own patients from the ED. That way you end up taking more responsibility for your decisions about who would benefit from inpatient stay (as opposed to who just might meet legal criteria or who just want an admission).

 

[calvnandhobbs68]

However, from a systems perspective, I prefer that psych ED's are attached to inpatient units and inpatient physicians admit their own patients from the ED. That way you end up taking more responsibility for your decisions about who would benefit from inpatient stay (as opposed to who just might meet legal criteria or who just want an admission).

Oh yeah 100%. The absolute worst as a resident was when they'd have these telemedicine "consult" services that would see patients in the ED when they regular ED service was so backed up that wait times were bad but these stupid services would just literally admit every patient with terrible histories and you'd basically have to piece everything together yourself inpatient about why the hell the person was even admitted. The incentive when you have no skin in the game is just too strong to admit for simplicity sake ("the inpatient team will just figure it all out in the morning"), liability and just plain laziness a lot of times.

 

[Merovinge]

Out of curiosity - are places you described which are run by an MD actually better? I can envision an IOP that is run by a PhD and which uses an MD 1-2 days a week to meet with patients being a quality program. I feel like there are many non-MDs who provide significantly better therapy than myself - I can't imagine myself as the head of an IOP doing better than them.

I don't have a point of comparison to working for a non-MD run PHP/IOP. I am comfortable having worked IP during residency/fellowship/attending time being the lead for patients with psychiatric illness and I think MDs are uniquely positioned to do that in the mental health space (I think most folks agree even in allied fields). Psychologists are invaluable for these programs to design curriculum, supervise the therapists, see tough cases for individual or family therapy, but at the end of the day it's my license and my decision for LoC, who we can best treat, who has medical issues that need other treatment and so on.

I was not trained to be a hired gun to provide brief med evals so that other mental health folks can run their treatment programs, I just don't understand wanting to be part of that, but if that's your inclination the opportunities certainly abound.

 

[clozareal]

Favorite: CAP outpatient (children get better quickly especially with psychotherapy, families usually wanting their kid to do well with some exceptions, parents really appreciative) & C-L (lots of interesting med-psych interface)

Least favorite: inpatient (too high acuity, hate coercive/involuntary work), emergency (too acute, crises and violence make me anxious), addiction (too many controlled med seeking patients, had bad experiences with patients getting aggressive/assaultive)

 

[G Sheb]

I do CL work at a large academic center and see some of the most complex and interesting cases there. You do need to know your medical stuff if you want to do good work and at times it does feel humbling if you have not been fully trained in CL.
Outpatient is my favorite and but like others, I cannot do this full time especially if therapy is a focus.
I really enjoy ER as well as you are seeing so much florid pathology and clinical decision making/ability to accurately evaluate evidence is really important.
Probably least favorite is inpatient. I did enjoy it as a resident but I think there are so many issues with how the US system functions. Poor communication with outpatient providers means so many inpatient doctors feel free to change the whole regimen for the usual zombie cocktail which ends up making the hospitalization potentially worse for the patient. Then because of the 'average' discharge time and pressure from hospital administration and insurance companies, it means patients are prematurely discharged.

 

[allantois]

Favorite: CAP outpatient (children get better quickly especially with psychotherapy, families usually wanting their kid to do well with some exceptions, parents really appreciative) & C-L (lots of interesting med-psych interface)

Least favorite: inpatient (too high acuity, hate coercive/involuntary work), emergency (too acute, crises and violence make me anxious), addiction (too many controlled med seeking patients, had bad experiences with patients getting aggressive/assaultive)

Idk where you are finding these CAP cases. Usually there’s family dynamics issues and parents are the ones needing therapy.. props for liking the work tho

 

[calvnandhobbs68]

Idk where you are finding these CAP cases. Usually there’s family dynamics issues and parents are the ones needing therapy.. props for liking the work tho

Residency/Fellowship outpatient CAP clinics aren't great because
1) You're in a residency clinic, you're generally getting the subset of patients the private practices don't want/can't get into a private practice
2) You have no control over the patient population (no matter how many no shows, stupid phone calls or failure to follow through on recommendations you have, programs generally don't let you discharge or set restrictions with many patients)
3) You may be one of the only clinics in the city/area that takes medicaid, so you're getting a big medicaid population which can be pretty discouraging in CAP as lots of people want you to call SES problems "psychiatric" problems and fix them with medication (ex. you live in a one parent household with multiple other siblings, your parent can barely hold down a job, you have to go to a school with terrible academics and kids fighting in the hallways every day, walk past people dealing drugs outside your building on your way to/from school every day and have to worry about getting shot by stray bullets coming from the gunshots you're hearing down the street every other day? Yeah I think I'd be anxious and depressed too kid, don't think prozac is gonna fix this one)

Outpatient private practice (not talking cash only high end private practice either) can look way different. Families are still a pain a lot though but that's just part of the territory of doing child/pediatric any speciality. I personally would take the worst family I've had in private practice over a terrible geriatrics case any day of the week but that's just me.

 

[Merovinge]

Residency/Fellowship outpatient CAP clinics aren't great because
1) You're in a residency clinic, you're generally getting the subset of patients the private practices don't want/can't get into a private practice
2) You have no control over the patient population (no matter how many no shows, stupid phone calls or failure to follow through on recommendations you have, programs generally don't let you discharge or set restrictions with many patients)
3) You may be one of the only clinics in the city/area that takes medicaid, so you're getting a big medicaid population which can be pretty discouraging in CAP as lots of people want you to call SES problems "psychiatric" problems and fix them with medication (ex. you live in a one parent household with multiple other siblings, your parent can barely hold down a job, you have to go to a school with terrible academics and kids fighting in the hallways every day, walk past people dealing drugs outside your building on your way to/from school every day and have to worry about getting shot by stray bullets coming from the gunshots you're hearing down the street every other day? Yeah I think I'd be anxious and depressed too kid, don't think prozac is gonna fix this one)

Outpatient private practice (not talking cash only high end private practice either) can look way different. Families are still a pain a lot though but that's just part of the territory of doing child/pediatric any speciality. I personally would take the worst family I've had in private practice over a terrible geriatrics case any day of the week but that's just me.

I was very worried coming to work in a moderately affluent suburb that is close to a major city, but it's been way better than expected. I very rarely have unreasonably demanding families and far more often have very involved families that are both grateful, supportive, and provide structure/adherence assistance that makes outcomes far better than adult psychiatric practice. It shouldn't be a big surprise, but it turns out when people have their basic needs met and aren't struggling with their own severe mental illnesses they really do want the best for their kids.

 

[clozareal]

Residency/Fellowship outpatient CAP clinics aren't great because
1) You're in a residency clinic, you're generally getting the subset of patients the private practices don't want/can't get into a private practice
2) You have no control over the patient population (no matter how many no shows, stupid phone calls or failure to follow through on recommendations you have, programs generally don't let you discharge or set restrictions with many patients)
3) You may be one of the only clinics in the city/area that takes medicaid, so you're getting a big medicaid population which can be pretty discouraging in CAP as lots of people want you to call SES problems "psychiatric" problems and fix them with medication (ex. you live in a one parent household with multiple other siblings, your parent can barely hold down a job, you have to go to a school with terrible academics and kids fighting in the hallways every day, walk past people dealing drugs outside your building on your way to/from school every day and have to worry about getting shot by stray bullets coming from the gunshots you're hearing down the street every other day? Yeah I think I'd be anxious and depressed too kid, don't think prozac is gonna fix this one)

Outpatient private practice (not talking cash only high end private practice either) can look way different. Families are still a pain a lot though but that's just part of the territory of doing child/pediatric any speciality. I personally would take the worst family I've had in private practice over a terrible geriatrics case any day of the week but that's just me.

Agreed. The residency CAP clinics and the CMHC had **** show parents as patients sometimes. I found that the Medicaid patient population to often be entitled and have unreasonable expectations for their complex issues which seems to be less so the case with middle class, blue collar private insurance based clinics.

My private practice also has many affluent patients who are often well resourced and motivated enough to mobilize any recommendations I make so I often feel more effective. I worried about entitlement in that patient population but it hasn't been the case at all with the exception of wanting sooner and more flexible hours for appointments.

Thankfully, even the complex cases that I get in private practice either 1) get better to the point where they are no longer train wrecks or 2) don't stick around in my private practice because I either reject them after the initial consult as not a good fit or they realize how much work they need to put in with my thorough recommendations (often family therapy, environmental changes at home, many changes at school, etc) so they drop off.

I agree with calvinandhobbs68 in that the worst patient I've had in private practice is loads better than a personality disordered patient in my residency/fellowship clinic.

Idk where you are finding these CAP cases. Usually there’s family dynamics issues and parents are the ones needing therapy.. props for liking the work tho

Oh yeah I often do family and parent therapy. The CAP fellowship really helped me learn and develop tools to identify and intervene effectively on family dynamics that cause problematic issues for the kid. I didn't get that in residency.

Throughout my medical education, whenever I had trouble treating something, I often eventually discovered I lacked experience in a certain skillset or knowledge about that condition. When I developed my skillset in working with parents, families, children, and adolescents, the work became much easier and more enjoyable although I did enough of a baseline interest and enjoyment prior that led me to pursue fellowship training. However, no matter how much I learn DBT, GPM, psychodynamic/psychoanalytic psychotherapy, TFP, MBT, I don't think I'll ever have a high preference for treating borderline personality disorder even with the high remission rates over time.

 

[allantois]

Admittedly I really do enjoy working with BPD patients; maybe because I can identify some BPD traits in myself. I just find PD patients to be absolutely fascinating

 

[smalltownpsych]

I don't have a point of comparison to working for a non-MD run PHP/IOP. I am comfortable having worked IP during residency/fellowship/attending time being the lead for patients with psychiatric illness and I think MDs are uniquely positioned to do that in the mental health space (I think most folks agree even in allied fields). Psychologists are invaluable for these programs to design curriculum, supervise the therapists, see tough cases for individual or family therapy, but at the end of the day it's my license and my decision for LoC, who we can best treat, who has medical issues that need other treatment and so on.

I was not trained to be a hired gun to provide brief med evals so that other mental health folks can run their treatment programs, I just don't understand wanting to be part of that, but if that's your inclination the opportunities certainly abound.

I disagree only to the extent that I think I could run one better than you! 😉 Seriously though, I really think it depends on the individual, but I do think it is important to have a clinician in the leadership role and that they should be doctoral level and that I would lean towards an MD being better situated for that role mainly because of the extra clout you guys have from a legal and societal standpoint. I also don’t think enough psychologists put themselves in these types of leadership roles and I wish we would because I do think many of us have the skills to do well in them and they often get filled by the more bureaucratic types which is one reason why so many of these programs are so poorly run.

 

[Merovinge]

I disagree only to the extent that I think I could run one better than you! 😉 Seriously though, I really think it depends on the individual, but I do think it is important to have a clinician in the leadership role and that they should be doctoral level and that I would lean towards an MD being better situated for that role mainly because of the extra clout you guys have from a legal and societal standpoint. I also don’t think enough psychologists put themselves in these types of leadership roles and I wish we would because I do think many of us have the skills to do well in them and they often get filled by the more bureaucratic types which is one reason why so many of these programs are so poorly run.

The programs I have seen run by psychologists have really neglected the medical aspect of treatment. Suboptimal pharmacologic management by a contracted MD who clearly is minimally involved in the program, suboptimal lab evaluations, suboptimal interactions with MDs of other specialties or referrals out to other doctors (the list goes on).

I can absolutely see a co-founded RTC/PHP/IOP with an MD and PhD being wonderful or a co-equal setup with a MD and PhD as the clinical leads. There is a tiny subset of PhD psychologists who have extensive experience in the hospital/IP/RTC space that take a liking to this work with great expertise (some of which are present on this forum), but I find the majority don't know what they don't know and this leads to neglect of a critical component of treatment.

100% agree that have a MBA being the lead of the program is a perfect way to know where not to get care at. There are still bad programs run by doctorate level clinicians but the rate is definitely going to be less.

 

[psychmd03]

Personally I love inpatient work and prefer to work with very sick patients. The more manic and/or psychotic the more depressed they are the more I like to work with that subset of patients. It is more rewarding to me and much more interesting. Also inpatient allows me to make my days flexible and there are no late patients to throw off my schedule. I also really like the team aspect of IP. I enjoy working with my SW and nurses (90% of them at least).

OP to me is the worst combination of boring as well as I am captive to my patients and a set in stone schedule. I am very glad that the majority of psychiatrists like this work. It is very important but I just am not in a spot in life where it is enjoyable.

 

[comp1]

For me, another aspect of loving inpatient is that our meds are mostly really for severe illness. Now yes, much of what you see in inpatient is socioeconomic related, but treating florid schizophrenia or bipolar mania with an antipsychotic has just a much higher likelihood of having an observable effect than treating mild situational depression with an antidepressant.

 

[whopper]

Every field has it's ups and downs.
Outpatient: Some patients are emotionally draining and you will continue to see them long-term. You don't have intense ability to monitor the patient so lots of what you accept as going on is based on trusting them to tell you the truth.
Inpatient: You can't control what happens after the person leaves.
ER: Lots of malingerers. Lots of BS cases that shouldn't have been sent to the ER in the first place.
Consults: Lots of consults that shouldn't have been ordered in the first place.

Overall, and sincerely, I loved all aspects of psychiatry. While in academia I wanted my clinical rotations once in awhile switched to keep fresh in each field.

I, however, chose private practice in the end. Why? Cause it made the most money at least for my situation and I could had more control over the BS factors. E.g. in consults I came to realize why there were so many BS consults. Cause the program had the residents do it, the residents were cheap labor and none of the attendings gave a crap if the residents were mired in BS consults (although it still annoyed the heck out of me). So the mechanism to create balance-telling the hospital admins to create protocols before a consult could be ordered, to call up the consult psychiatrist first to see if this consult was avoidable and creating financial incentives (e.g. paying the psychiatrist per consult) weren't being done and no one cared enough to make it happen.

In my own private practice cause I'm the top administrator I have more control over this BS. I came to see BS that ticked me off in every field, and often times the buck stopped in someone's lap who wasn't doing much to fix it or not enough IMHO. In my own private practice the buck stops with me, I have control over it and I can get it fixed ASAP instead of asking a bureaucrat over and over and over for weeks to get the problem solved.

I miss doing inpatient the most, but where I'm currently situated, I cannot work in inpatient unless I commit to a hospital, and all of the hospitals I've seen in the area have too much BS associated with them. E.g. while at U of Cincinnati the ER psych did a good job at filtering out malingerers. It was a simple equation-we came to know the frequent flyers and knew who really needed help and who didn't. If they didn't need help they were not admitted. If we weren't sure we'd admit to give the benefit of the doubt but usually by day 3 the social worker and the psychiatrist had it figured out well and then documented on the discharge so the next time they showed up in the ER, ER psych would know the gritty details. E.g. "patient has frequent self-mutilation within the context of a Borderline Personality trait and doesn't have a desire to kill herself. The Columbia scale puts her at low risk for a future-suicidal event." Or "Patient has a known history of exaggerating symptoms of mental illness. Several times the patient was observed by providers contradicting symptoms of depression. For example the patient was seen boasting to other patients that he's not really mentally ill and only in the hospital for free housing. This was recorded by Nurse X. Also while directly interviewed he exhibited signs of dysphoria, when the patient was observed for hours his signs did not match his symptoms with the patient often times seen carousing with other patients, making sexual advances, and was seen making phone calls on business deals."

Where I'm at now I haven't seen this level of expertise. I haven't seen a hospital in this city where ER psych and inpatient have that level of understanding. The ER admits pretty much anyone who claims to be suicidal or self-mutilates, and the inpatient doctors and social worker didn't document the gritty details that could help avoid future unnecessary admissions for the specific patient and because of it when I did inpatient I'd be discharging about 85% of the people who were on day 1. That too me was too much BS to deal with cause as everyone here knows the most amount of paperwork are the new admits and the discharges, so imagine having 5 new patients in 1 day and you're discharging 4 of them day 1, and you know the ER psych doesn't care, and then literally 3 days later 3 of those people are back.

I did the right thing-I tried for over 6 months to address this issue and recommend and said I'd do the work to make these things become reality. The next higher up ignored me, my colleagues didn't care. (At U of Cincinnati aside that they were already on top of this problem, if I had recommendations they'd work with me to make them reality and usually within a few weeks it'd happen and things got noticeably better).

Screw that. I left-to a new job that made over 2x as much and I was working about 1/3 less hours. Not to my surprise the prior institution's department imploded multiple times in the last 10 years. It just imploded again in the last year. Leaving them was the best thing I ever did for my income, happiness, and career.

 

[clozareal]

For me, another aspect of loving inpatient is that our meds are mostly really for severe illness. Now yes, much of what you see in inpatient is socioeconomic related, but treating florid schizophrenia or bipolar mania with an antipsychotic has just a much higher likelihood of having an observable effect than treating mild situational depression with an antidepressant.

You wouldn't use an antidepressant to treat mild situational depression anyways.

 

[whopper]

I should've mentioned this in my last post. My decision to do private practice, and my happiness with it isn't an absolute. Had I stayed in Cincinnati I realistically could've stayed a professor in functional institution with a much better retirement system and also been fine. So while I would've made less money there, I would've had a much better retirement that in the end could've possibly paid off even more depending on how long I lived (1/2 your salary for the rest of your life after 25 years).

The next job that I left-the retirement system sucked, the institution itself was dysfunctional, and instead of working to fix problems the powers that be (except the head of the department, he was great but people like him and I were outnumbered) didn't want to fix things. Add to that I'm in the midwest where there's a major thirst for psychiatrists.

So one could morph the last job into a "avoid academia" argument when in fact it really was an "avoid that last specific place (that I don't want to mention by name)." Had I done private practice in Cincinnati I believe I would've done well there too, but the need in that city is far less because so many good psychiatrists who are graduates of the program stay in the area. In my current city almost none of the graduates stay here. In Cincinnati it would've taken longer to develop a practice and to a degree where I think it made the idea of leaving the university (with it's good camaraderie, benefits, retirement, access to top minds in the field) not worth it.

I see so many attendings write things here as if things are absolute. So much of what's going on depends on several factors that where their information might not apply to your situation.

 

[whopper]

CL was the bane of my existence in residency. I'm not sure if it was because residents had zero power to refuse dumb consults (at least half) or because of the culture of "If there's no real psych problem, we'll find one."

This is a part of what I'm talking about in my above posts.

I'd love consults if all of them were valid requests and all of the people requesting were willing to work as part of a real team. I worked in 3 hospitals in residency, I don't know how many in medical school (over 10?), and as an attending over 10. In my work as a court officer I had to go to about 5 hospitals a week in Cincinnati (Summit, Mercy. VA, University Hospital, etc). After I moved out of Cincinnati I then worked in another hospital.

So I know what I'm talking about. Consults are dysfunctionally organized in every hospital I've seen. I've never seen any doctor like doing them no matter the field whether it be psychiatry, IM, surgery, Infectious Disease, whatever. It's even worse in residencies because the departments intentionally have the indentured-servants, "the help," er cough cough residents do them. At least when an attending complains the institution has some concern.

There's no protocols to prevent frivolous consults. There's no disincentives to prevent frivolous requests. There's no incentives for the consultant to do them. You don't get paid more to do them. If you do them and find this dysfunctional BS they don't listen to you if you want to fix the system.

Here's examples of protocols: 1-Why the consult (several of them did not state why). 2-Did you call the consultant before you requested to see if this consult was preventable? 3-Did you do the required protocols before requesting. E.g. if you requested a capacity consult did you discuss and document the discussion the risks and benefits of the procedure, the alternatives? What specifically calls into question the patient's capacity?

The reality is often times there was not even 1 reason requested. So we'd sometimes spend literally 30 minutes as to just why the consult was requested. So then this happens like 5x a day this was total BS. Often times with capacity consults the requesting physician never did the REQUIRED discussion on risks and benefits and alternatives. So then, and this is not appropriate, the psychiatrist would do them despite that often times the procedure/treatment/surgery in question was outside of the psychiatrist's field.

If I was the consultant in a hospital, had a decent baseline salary, had incentives to do consults such as more pay, and the requestor clearly stated why a consult was needed, and all the stuff was done so I didn't have to do the BS myself such as not spend 30 minutes on BS, I could see myself loving doing consults.

But hey what I wrote actually makes sense so it won't happen.

While I was a chief resident I put some of my plans in action and the head of the department backed me up. I knew I couldn't get away with all of my plans but did implement the ones I knew couldn't be argued against.

So I told the residents to refuse a consult if it was a capacity consult and the requesting physician didn't document they went over the risks/benefits and alternative treatments. The resident had to okay it with me. Within 24 hours a series of angry calls came in from attending physicians demanding to know why a capacity consult wasn't done and I told them to kindly talk to the hospital lawyer because they hadn't done the required minimum such discuss with the patient the risks/benefits and alternative treatments.

So for the next week I got several angry attendings, all of whom were asked to call the hospital lawyer, or I had the lawyer calling them. I had a lot of angry stares when I saw some of these doctors. The head of my department backed me up, and said "it's about time someone put their foot down" so I knew I was safe." On one occasion the hospital lawyer actually went to an angry doctor and told them I was correct and the physician was required to do what I requested. About 1 month later then all of a sudden capacity consults were having these minimal requirements done. The number of frivolous requests went down cause during the discussion the patient either changed their mind or picked the alternative treatment. Wow. So if you practice good medicine maybe the patient will be more prone to listen to you? What a shock.

On the flipside, the consultants on the other services (mostly IM) were happy with this especially cause I had our own residents do the same. They needed to try to avoid asking for an IM consultant using the same suggestions I put into place. The IM consultant told me is saved several frivolous requests.

I heard from a resident in the program the next chief didn't know WTF was going on and everything I pushed forward fell back to where it was. Not surprisingly the attendings didn't maintain what I did either. They were the ones who let this mess get to what it was in the first place.

 

[FlowRate]

Echoing what a lot of others said--I did CL in 3 different hospitals in residency. Hospitals A and A.affiliate had a reasonable consult culture. It really sucked to be at-bat and get the 4:55 PM consult but at least they pushed back against unreasonable consults. Hospital B had a toxic culture in the CL department--super overly-involved, zero pushback. (See: Liaison Psychiatrist as Busybody) I could see doing CL in a functioning system with reasonable guidelines/requirements/boundaries, but that seems to be exception. Thanks, I imagine, in large part to the culture of CL training institutions.

I think inpatient work as a resident didn't give me a fair taste of attending inpatient work. I never felt fully enabled to be the team lead so it amounted to a lot of busywork without ownership. I could see it being a lot more rewarding as an attending, provided you have, like with CL, a really good support team.

I overall like doing outpatient work. I'm happy that I have some admin FTE, 100% clinical (5x8) was getting to be a drag. I liked doing therapy in residency but it's not part of my current practice. I can't imagine doing proper 50-min therapy for 30+ hours a week, though--that sounds really draining.

 

[whopper]

I'm being very thorough and sorry if my answers are very long-winded.

The only field of psychiatry I didn't like was geriatric even with the BS removed. This is based on an assumption that you were doing the field the right way without all the BS. Like I said before I liked consults if it didn't have all the bull$hit, but because of hospital politics that field is mired down in bull$hit.

Reason why I didn't like geriatric psych was cause I didn't have enough victories/time that made me feel fulfilled. Most of my patients were demented, and like their family members getting depressed, I felt bad too. There are no great meds or game-changers with dementia treatment. Only the occasional misdiagnosis that you can correct (E.g. auto-antibody NMDA receptor encephalitis), but this is very rare.

Most of these cases there's hardly anything you can do that really makes a big difference. You can only slightly slow it down and slightly reduce the symptoms.

Occasionally I'd see a depressed geri-patient with dementia who'd say "who are you to not let me die if I want to die," and I thought if I were in the same situation I'd feel the same way. It made me stop believing in what I was doing in that area.

Now all this said this same field is also laden with the BS. Why? Cause (and I'm not attacking these people, it's understandable) you tell the patient he has dementia or some other advanced age issue and the patient's family wants to know. IF the patient didn't sign HIPAA of course you can't tell but often times the patient didn't sign HIPAA, might not even have the capacity to understand it, and there's no will or advanced directive or etc that allows you to communicate. Then you get the person's adult son screaming at you to tell him what's going on with his parent daily.

Or you're allowed to talk to the family and it turned out the patient did nothing to establish their estate and it's all up in the air and the family gets mad at you. "What do we do doctor? How will his estate transfer to us." Holy Jeez I'm a doctor-now an accountant or lawyer. WTF. Imagine this day after day after day while people are screaming at you. Yes of course there were social workers that tried to filter this stuff but several times they wouldn't accept data from a social worker. They'd insist on talking to "The Doctor."

"Doctor, our father never made a will. What do I do?"

All of this said, that's not to bash geri-psych. Just that it wasn't a good fit for me. It's heavily needed and I've seen some great geri-psychiatrists. I also highly suspect the family getting mad at me really got under my skin because I wanted to talk to them especially in what was a moment where they needed that discussion for their own healing and I wasn't able to give it to them. There's BS in every field but in inpatient geri-psych this was on the order of about biweekly where a patient's family became extremely upset with me for not violating HIPAA. A few times I year I even had to call the hospital lawyer to tell them to send the patient's family communication to stop harassing me.

I call it the Jerry Seinfeld Usher phenomenon. Ushers at movie theaters are teenage punks or elderly with almost no one in between. As he mentioned, it's the first job you ever get and then the last one you ever get. Same age demographics where you get a 30s-50s family member either the parent or child getting mad at you cause you won't violate HIPAA. Seriously. Double digits I get patients in the late teens or late 70s_+ and the family member keeps calling me over and over and over and there's no HIPAA release and I keep telling them I can't say anything.

 

[Celexa]

I love CL, and also agree with a lot of the issues raised in the thread. The devil is very much in the details of how the service is run, but isn't that true everywhere?

I also like outpatient. I like building relationships with pts and seeing them get better.

I strongly dislike inpatient psychiatry. I could imagine a theoretical type of inpatient that I wouldnt hate, but I don't think it exists anywhere in the American Healthcare system.

Also despise emergency psych, which should never be confused for CL. Dispo to all bad options most of the time. Ugh. Never again.

I am also very grateful to my ECT colleagues but actually doing it seems very boring.

 

[whopper]

A problem with CL is I've never seen 1 place where it's done well. Not 1 place out of over 20 hospitals, except for IM doing consults in psych institutions. I've seen a lot of places where inpatient and ER is done well.

 

[TheRightMedication]

I'd be curious to see your definition of CL done well. I, personally, pride myself on the adequacy of the CL service I provide. Rarely more, and I hope almost never less, than the situation demands. I'm willing to put some elbow grease into a risk assessment, complex pharm questions, or keeping placement issues outta the psych unit. Social issues and followup I leave to my betters in social work and nursing.

Consults for outpatient issues are the hardest to tune to adequacy - it's an annoying misallocation of psych resources. Yet, you do have a suffering human before you, and its not the case that the mental health system is so organized that you can redirect them. Sometimes there is an opportunity to help.

 

[Celexa]

A problem with CL is I've never seen 1 place where it's done well. Not 1 place out of over 20 hospitals, except for IM doing consults in psych institutions. I've seen a lot of places where inpatient and ER is done well.

I admit I find this surprising. I can't claim 20 hospitals experience but at each stage of training I moved system, and each system had multiple hospitals including affiliated VAs. Ive seen one place inpatient was done OK, all the others were bad. At some of the places the docs were good but everything else was horrible (nursing, infrastructure, medical care, pressures from the locally dominant insurance companies etc).

ED psych has been an unsafe ****show everywhere I've been.

In contrast although I have criticisms of the CL services I've been on, none have been anywhere near that bad. There was at least some attention paid to turning down the most absurd consults, making sure the teams did their due diligence prior to capacity assessments, and the art of figuring out what question you actually should answer, since often the one asked isnt it. Most consults I feel genuinely we are adding to the care of the patient, and enough of the time I feel appreciated by the teams to keep going.

Agree with you about geri tho... We get a lot of demented hospital boarders with behaviors and thats not enjoyable CL.

 

[psychmd03]

For me, another aspect of loving inpatient is that our meds are mostly really for severe illness. Now yes, much of what you see in inpatient is socioeconomic related, but treating florid schizophrenia or bipolar mania with an antipsychotic has just a much higher likelihood of having an observable effect than treating mild situational depression with an antidepressant.

This is also very true. I love seeing the dramatic changes you can see when you nail it. It only takes 3-7 days depending on the patient if it’s going well.

Also I forgot to mention being a 1099 at the inpatient hospital is even better yet imo as long as you can have it structured well.

 

[clausewitz2]

I loathed CL with a fiery passion during training, but state regulations make it uniquely terrible here. In our state anyone who has any kind of psych history has to receive a full psychiatric evaluation before they can be placed in any kind of SNF by law. So if Grandma saw a therapist in 1984 after her first divorce, she can't go to her placement until she gets a full psychiatric assessment. You say she has literally never complained about any kind of mental health difficulty this century? Too d**n bad, she sees psychiatry before she goes to the home.

The law was meant to prevent warehousing of people with mental illnesses, which was a noble goal, but also constitute a plurality of all inpatient C\L consults for obvious reasons.

 

[smalltownpsych]

I admit I find this surprising. I can't claim 20 hospitals experience but at each stage of training I moved system, and each system had multiple hospitals including affiliated VAs. Ive seen one place inpatient was done OK, all the others were bad. At some of the places the docs were good but everything else was horrible (nursing, infrastructure, medical care, pressures from the locally dominant insurance companies etc).

ED psych has been an unsafe ****show everywhere I've been.

In contrast although I have criticisms of the CL services I've been on, none have been anywhere near that bad. There was at least some attention paid to turning down the most absurd consults, making sure the teams did their due diligence prior to capacity assessments, and the art of figuring out what question you actually should answer, since often the one asked isnt it. Most consults I feel genuinely we are adding to the care of the patient, and enough of the time I feel appreciated by the teams to keep going.

Agree with you about geri tho... We get a lot of demented hospital boarders with behaviors and thats not enjoyable CL.

Might be that these were bigger systems in metro areas and more likely to be crap shows. I worked in some smaller hospitals in rural areas and covered the ED for psych consults and it was relatively straightforward and well done. The biggest problem we had was one Psych NP getting into ego battles with nurses and ER docs because of her own insecurities. In a small system, we could work through that. I imagine in a bigger system it could have led to much more problems.

 

[Celexa]

I loathed CL with a fiery passion during training, but state regulations make it uniquely terrible here. In our state anyone who has any kind of psych history has to receive a full psychiatric evaluation before they can be placed in any kind of SNF by law. So if Grandma saw a therapist in 1984 after her first divorce, she can't go to her placement until she gets a full psychiatric assessment. You say she has literally never complained about any kind of mental health difficulty this century? Too d**n bad, she sees psychiatry before she goes to the home.

The law was meant to prevent warehousing of people with mental illnesses, which was a noble goal, but also constitute a plurality of all inpatient C\L consults for obvious reasons.

If you did residency at the program I think you did.... Let's just say your hospital system had a unique way of interpreting that law bc that's not how it is everywhere in the state.

 

[clausewitz2]

If you did residency at the program I think you did.... Let's just say your hospital system had a unique way of interpreting that law bc that's not how it is everywhere in the state.

I can buy this. Our hospital system's lawyers also decided that we basically had legal authority to hold people overnight in a medical hospital if they tried to leave AMA without having to initiate any kind of involuntary commitment proceedings, which seems...alarming.

EDIT: Actually reviewing the state DHS policies and regs on this, a simple screen definitely triggers a review that is fairly exhaustive in terms of the information demanded to complete the required certification forms. I don't see how you could complete it without a fairly thorough psych eval. Any history of diagnosis with

"Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Psychotic Disorder, Personality Disorder, Panic or Other Severe Anxiety Disorder, Somatic Symptom Disorder, Bipolar Disorder, Depressive Disorder, or another mental disorder that may lead to chronic disability"

appears to trigger the process.

 

[Celexa]

I can buy this. Our hospital system's lawyers also decided that we basically had legal authority to hold people overnight in a medical hospital if they tried to leave AMA without having to initiate any kind of involuntary commitment proceedings, which seems...alarming.

EDIT: Actually reviewing the state DHS policies and regs on this, a simple screen definitely triggers a review that is fairly exhaustive in terms of the information demanded to complete the required certification forms. I don't see how you could complete it without a fairly thorough psych eval. Any history of diagnosis with

"Schizophrenia, Schizoaffective Disorder, Delusional Disorder, Psychotic Disorder, Personality Disorder, Panic or Other Severe Anxiety Disorder, Somatic Symptom Disorder, Bipolar Disorder, Depressive Disorder, or another mental disorder that may lead to chronic disability"

appears to trigger the process.

I am certain this was all handled by social work at the institutions I am familiar with. It would only rise to the level of the CL team of there were a much higher level of concern and specific symptoms and/or behaviors.

 

[Stagg737]

Lots of stuff I'd love to discuss further, but to the OP's original question:

Love: C/L at the large academic institution I did residency. Saw things that some docs may never see in their lives and a few things other psychiatrists hadn't even heard of (apotemnophelia anyone?). Yes, there are garbage consults even in well-run systems, but I love the need to really keep up non-psychiatric medical knowledge and the variety of things you see. Also inpatient psych to a slightly lesser extent as this was what initially sparked my interest in psych and the dramatic changes that occur by restarting manic patients on the right med still blows my mind at times.

Hate: Employed outpatient. PGY-3 was the worst year of my life in terms of education/career and there were points that I legitimately asked myself if I really wanted to continue with psychiatry. If outpatient year were during PGY-1 I'm 100% certain I wouldn't be a psychiatrist right now. Imo it would be different in PP where you can pick all your own patients and how you practice (PGY-4 wasn't as bad), but I still couldn't do this FT. Plus a strict schedule is gross.

 

[whopper]

I can buy this. Our hospital system's lawyers also decided that we basically had legal authority to hold people overnight in a medical hospital if they tried to leave AMA without having to initiate any kind of involuntary commitment proceedings, which seems...alarming.

I don't know what state this is but in NJ, at least while I was there, there was a law where if you entered an ER once processed as a patient you couldn't leave the ER until a doctor let you go.

So quite a few patients who didn't have a psych complaint became psych inpatients cause after waiting for over 10 hours wanted to leave, the ER doctor hadn't yet seen them, the patient got mad, said "you can't hold me this is illegal" and tried to walk out, was Haldoled and woke up in the psych unit.

Personally, I believe this was unconstitutional but one of those things where it has to be challenged in a federal court for it to be taken out of the law books.