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Billing/coding (especially how to use therapy add-on codes), how to structure your visits to be efficient with note-taking + meet insurance requirements, how to structure a focused visit to avoid getting overwhelmed with all of the patient's problems and trying to hone in on what is most relevant.
I agree with this and would say this is part of why I hate outpatient. Sometimes the problem is easy to identify and keep narrow with treatment. However, once you get more into the optimization phase of treatment things get much more cloudy in terms of what we can/should help with.This is absolutely the critical learning task of the outpatient years. Inpatient or ED it is much easier to keep your focus tight, there are a limited number of moves you have. Outpatient, you drown if you aren't ruthless about this (especially if your can't arrange for relatively frequent follow-up).
This is true, but I think it's equally important to define what being "well" actually means. Many patients have an unrealistic expectation that we can help them feel happy all or most of the time or that they shouldn't have to feel sad or anxious. Understanding that educating these patients on what we can actually do and that negative feelings are not only normal but healthy and important is something I feel many outpatient psychiatrists rarely talk about. Especially those doing the 15 minute med-check appointments.Oh, and another critical inpatient thing to unwind--the goal of inpatient is to be well enough to be discharged. The goal of outpatient is to be well . Totally different and easy to forget.
This is true, but I think it's equally important to define what being "well" actually means. Many patients have an unrealistic expectation that we can help them feel happy all or most of the time or that they shouldn't have to feel sad or anxious. Understanding that educating these patients on what we can actually do and that negative feelings are not only normal but healthy and important is something I feel many outpatient psychiatrists rarely talk about. Especially those doing the 15 minute med-check appointments.
Ha. Yes. My version is something like "my goal is for you to be able to live life without your mental health being major barrier. That means being able to access and experience the range of positive and negative emotions that are part of being alive". There's a reason I say "well" and not "happy".I have conversations about this pretty regularly. "So we do actually have a medication that can just make you feel good all the time if you take it really consistently. It's called heroin. It turns out to have some downsides."
I have conversations about this pretty regularly. "So we do actually have a medication that can just make you feel good all the time if you take it really consistently. It's called heroin. It turns out to have some downsides."
Mine is a bit more cynical. A lot of patients just want to numb their negative emotions and I let them know that I'm a psychiatrist, not an anesthesiologist.Ha. Yes. My version is something like "my goal is for you to be able to live life without your mental health being major barrier. That means being able to access and experience the range of positive and negative emotions that are part of being alive".
Ideally the goal of outpatient should be to make the person well enough to discharge just as much as inpatient. I'm not sure I've ever met anyone who was "well" in the Platonic Ideal sense of the word. My own system has immense trouble with psychiatry attendings holding on to easy and stable patients with death grips for all eternity. PCPs need them back or you won't have space for the patients you haven't even met yet who need your care. Admittedly, this is kind of complex, very systems driven, and most attendings haven't mastered outpatient discharges (other than for problematic patients) because there is often a financial disincentive to do so.
Sure, but this is more of a problem with those PCPs not meeting basic standards of care/knowledge than anything. Yes, there are plenty of psych patients who should stick with a psychiatrist long-term d/t SMI or being on certain meds that really should be managed by a specialist. However, most psych patients don't have SMI/SPMI and should be able to return to a PCP at some point.That's fine when it can happen but there are a lot of outpatients who end up so doing well on medications their PCP won't touch with a ten foot pole. These people will probably need a steady outpatient psychiatrist long-term.
It's definitely a two way road, but if you aren't changing meds and are only seeing the patient every 3-6 months, it's time to go back to the PCP even if they're on three different meds or an adjunctive antipsychotic or whatever weird barrier the PCP tries to throw up. Good systems will facilitate this, smooth it out and prohibit inappropriate barriers. It helps no one to have SMI patients out there without access because a PCP is scared of refilling stimulants. Of course this is a thread about resident education, so I guess what you can do is model discharging patients back to PCPs regularly even if that means having a full on supportive psychotherapy session with said PCP. I get that this is still very much an issue within academic centers, but it should not be. You gotta fix it in academia so there's some hope for private practices where the financial incentives are horribly perverse.
Totally agree but doubt they are passing on the adult stimulant patients out of fear. 😉It helps no one to have SMI patients out there without access because a PCP is scared of refilling stimulants.
"If you want to feel good, use heroin. If you want to feel bad, keep using heroin. If you want to feel awful, stop using heroin."I have conversations about this pretty regularly. "So we do actually have a medication that can just make you feel good all the time if you take it really consistently. It's called heroin. It turns out to have some downsides."
"If you want to feel good, use heroin. If you want to feel bad, keep using heroin. If you want to feel awful, stop using heroin."
Also, trivia: Heroin should be capitalized, because it is the brand name for diacetylmorphine (approved in UK, not in US).
Totally agree but doubt they are passing on the adult stimulant patients out of fear. 😉