Exit Strategy

[Antares]

I'm sorry I didn't see this sooner. I'm a psychiatrist too. Early in my career, I realized that for me the available jobs working for others would be too stressful, unrewarding, and leave me with too little control over my work life. Inpatient work as a career would have killed me. I'd have been burned out too, wondering why the ************************ I'd spent my youth just to wind up putting psychiatric bandaids on very sick people and sending them back out again. The patients are all admitted in an acute state of extreme need, which cannot be in any adequate way dealt with in a short inpatient setting. And the inpatient psychiatrist is in the position of being stressed from the workload, and the paperwork, and whether aware of it or not, stressed from dealing with the the potent emotional baggage of the breakdown in patients' ordinary defenses and the resulting toxic psychological stew. Of course you're burned out.

My recommendation would be to transition over time to your own outpatient practice. Your pay would be higher on an hourly basis, you would have no boss to plead with for better working conditions and hours, you would have tremendous control over how many hours you want to work, which patients you are willing to work with, whether to work one day a week or five. There might be availability by phone after hours, but absolutely no actual weekend work. And if you are judicious, you can have a practice of relatively stable patients who don't need to call you between meetings.

I know outpatient practice varies place to place, so transitioning in your area would involve strategizing about the particulars. I have a cash only practice, four days a week, very manageable stress, and do 70%/30% therapy plus psychopharm/psychopharm only. My approach, which may or may not work for you, was to build a small practice on the side, go part time, build up some more, and then quit the job and build the rest of a full time practice.

One more thing. I wouldn't rule out the possibility that you may have some depression on top of burn out. Don't be your own doctor. Get an independent assessment. The idea that getting help wouldn't or couldn't be beneficial is a common feeling in depression.  Could be wrong, and certainly would like to be.

Good luck! I'm sure there are better options for you out there.

[Lithium]

I really hated outpatient work in my third year of residency.  Maybe a lot of that had to do with working with mostly low-income Medicaid patients, many of them wanting Xanax and Adderall, and many of them also requiring PA's for 20 mg of fluoxetine a day, who called twice between every monthly appointment and wanted to do therapy over the phone.  But continuity of care in general is a big turn-off for me, and the idea of never being able to get away from work or that the patients could call me from a campground or movie theater at any time would be a total dealbreaker.

Some ideas I've kicked around besides short-term locums inpatient assignments would be working in the correctional setting or a TMS center on a part-time 1099 basis.  I think I have a good employer all things considered, but whenever I leave this one I don't think I'll try to find another one.  There is too much contractual risk, antagonism in goals ("provider" productivity vs. life/work balance), and institutional rigidity to change.

[Hatton]

I have a friend who is a Psychiatrist.  She works 3 days per week. I have to call her before she will accept a referral.  She only takes cash.  She shares office space with a counselor and a child psychiatrist. No EMR. She is very happy I think and in total control of her life.

[Antares]

hatton1 wrote:

I have a friend who is a Psychiatrist.  She works 3 days per week. I have to call her before she will accept a referral.  She only takes cash.  She shares office space with a counselor and a child psychiatrist. No EMR. She is very happy I think and in total control of her life.

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Absolutely. That sounds like me, except I work 4 days. I triage heavily before saying yes to a referral. That practice has kept my work life manageable.

[Antares]

Lithium wrote:

I really hated outpatient work in my third year of residency.  Maybe a lot of that had to do with working with mostly low-income Medicaid patients, many of them wanting Xanax and Adderall, and many of them also requiring PA’s for 20 mg of fluoxetine a day, who called twice between every monthly appointment and wanted to do therapy over the phone.  But continuity of care in general is a big turn-off for me, and the idea of never being able to get away from work or that the patients could call me from a campground or movie theater at any time would be a total dealbreaker.

Some ideas I’ve kicked around besides short-term locums inpatient assignments would be working in the correctional setting or a TMS center on a part-time 1099 basis.  I think I have a good employer all things considered, but whenever I leave this one I don’t think I’ll try to find another one.  There is too much contractual risk, antagonism in goals (“provider” productivity vs. life/work balance), and institutional rigidity to change.

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So maybe a small, contained, high hourly paying, low stress outpatient practice is not for you. But consider: you say yes or no to the referral. If you don't want to treat Medicaid patients you don't have to. If you don't want to prescribe stimulants and benzos, you don't have to. If you find yourself in the position of someone calling you inappropriately, you addresss that with them, and most of them won't do it again. If they do, you have set the stage for terminating the treatment if you wish by addressing the conditions under which you can work with them. If they are calling appropriately, maybe this is not a patient you feel you can manage, and you would help them find another treatment or practitioner. Honestly, this happens to me so rarely now that I am careful about who I accept, that to me it seems a remote consideration. But ymmv. Certainly it's not the only option.

[beagler]

Private practice and outpatient practice seem to have little draw for current younger physicians. As an employee or inpatient physician: vacation is covered, clock in clock out, no business knowledge needed. Lots of young docs signing up to be hospitalists.

Shift work is convenient, but I wouldn't underestimate the toll of shift work. Nor would underestimate the sustaining power of ongoing relationships with our patients.

Long-term relationships with appreciative, pleasant patients provides great career sustenance. This includes those whose primary problem is psychiatric (although a smallish percent for me).

Running one's practice is challenging mainly due to no leverage with insurance companies, but we have other levers one can control. If I'm not happy in private practice I can basically blame myself, but also I have the power to fix it myself.

[Lithium]

The big problem with outpatient work is that, probably because of my attachment style, I don't find the long-term relationships to be satisfying and 90% of the time just want those patients to go away at some point.  I am pretty rigid with boundaries and dislike it when ancillary staff leak any personal details about me, and when the transference/countertransference dynamic becomes an issue I'm not that comfortable with it, especially with the patients who want to be my friend.

Outpatient telepsych might not be that bad if there were sufficient distance and if it got me out of the 24/7 call problem.

[FIREshrink]

I do outpatient psych and am not on call 24/7. I am on call one night per week and never get called. We train our patients to use the crisis line or the ED.

 

You say that seeing a psychiatrist would not help you, but also describe certain 'attachment' styles which limit your ability to enjoy long term relationships with patients. With others, too? Becoming content in a career has a lot to do with contentment in life, in other relationships, with oneself. But you know all that.

[Lithium]

Meh.  I understand my strengths and weaknesses, and I'm not trying to change who I am.  Maybe I should have just gone into pathology.  I also know what my field can do, and one thing I haven't seen it do very well is help people find "contentment in life."  The best it can possibly do is serve as a catalyst, but in life you don't get a designated hitter.  It's still on you to answer the tough existential questions and step up to the plate and swing.

I guess others may wish to counter that existential psychotherapy is really helpful and it helps not to go through challenging times in your own mental echo chamber, etc, but I really think this is a red herring.

[Antares]

Lithium wrote:

Meh.  I understand my strengths and weaknesses, and I’m not trying to change who I am.  Maybe I should have just gone into pathology.  I also know what my field can do, and one thing I haven’t seen it do very well is help people find “contentment in life.”  The best it can possibly do is serve as a catalyst, but in life you don’t get a designated hitter.  It’s still on you to answer the tough existential questions and step up to the plate and swing.

I guess others may wish to counter that existential psychotherapy is really helpful and it helps not to go through challenging times in your own mental echo chamber, etc, but I really think this is a red herring.

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I see it differently. Discontent with life is a great place to start a psychotherapy. I find it gratifying to help people with their existential issues. I consider it sort of a subspecialty of mine. But it makes sense that you wouldn't want to do a lot of therapy professionally if you don't believe it's helpful.

Maybe retraining in another specialty isn't the worst idea?

[Zaphod]

Lithium wrote:

Meh.  I understand my strengths and weaknesses, and I’m not trying to change who I am.  Maybe I should have just gone into pathology.  I also know what my field can do, and one thing I haven’t seen it do very well is help people find “contentment in life.”  The best it can possibly do is serve as a catalyst, but in life you don’t get a designated hitter.  It’s still on you to answer the tough existential questions and step up to the plate and swing.

I guess others may wish to counter that existential psychotherapy is really helpful and it helps not to go through challenging times in your own mental echo chamber, etc, but I really think this is a red herring.

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Not knocking anyones specialty but there have been several studies apparently that showed no difference if the therapist or the patient did the psychotherapy.

Now, full disclosure, these were headlines, I did not read the underlying studies and dont even know if they were talking about M.D.s or whatever. Your comment just reminded me is all.

[wideopenspaces]

Lithium wrote:

A brief update:

i’ve contacted the director at the hospital 30 minutes away, and the jobs there are more promising.  I would have the option to do basically what I’m doing now, but see a higher volume of patients now for about 23 weeks a year rather than fewer for 36.  16 weeks off a year sounds like a lot, but it is the 36 weekends in the hospital every year that are a killer.  For example, Monday was my first day off in August.  I’ll probably take a week to think this over, but it seems like a good option for now.

I’m selling my house because I live alone and don’t like taking care of it.  The market is also pretty favorable, and I would rather have the freedom to pick up and move if I decide I want to leave.

 

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That sounds promising! It might at least allow you to make it to 5 years to get the pension (not that it really matters in your situation . . .). And give you time to figure out your next move. I hope it at least allows you to improve the quality of your life outside of work. You'll have to keep us posted!

[childay]

Lithium wrote:

i’ve contacted the director at the hospital 30 minutes away, and the jobs there are more promising.  I would have the option to do basically what I’m doing now, but see a higher volume of patients now for about 23 weeks a year rather than fewer for 36.

Click to expand...

It sounds like you might actually like (or at least prefer) inpatient work, if you weren't working so hard.  Working 23 weeks a year sounds like you must be working extremely hard those weeks!  Can you not find a job with reasonable patient load / administrative duties?  I'll ask again how many patients you are seeing or would be seeing in this new job?  Hard to know if all those weeks off would balance for the other 23..

[Lithium]

childay wrote:

Lithium wrote:

i’ve contacted the director at the hospital 30 minutes away, and the jobs there are more promising.  I would have the option to do basically what I’m doing now, but see a higher volume of patients now for about 23 weeks a year rather than fewer for 36.

Click to expand…

It sounds like you might actually like (or at least prefer) inpatient work, if you weren’t working so hard.  Working 23 weeks a year sounds like you must be working extremely hard those weeks!  Can you not find a job with reasonable patient load / administrative duties?  I’ll ask again how many patients you are seeing or would be seeing in this new job?  Hard to know if all those weeks off would balance for the other 23..

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Right now I see what would be considered probably a light patient load, but high turnover makes it more taxing, and the add on work I do makes it even more so.  My efficiency sucks right now honestly, probably due to dissatisfaction, burnout, not feeling fresh, etc.  If I took this different job I'd be seeing a more average patient load (12 pts or so) with probably average turnover.  Most of the doctors there are workhorses who have a clinic in their off weeks, but I'd have no pressure to do so.  The big drawback at this new place is there's a lot more call.  I don't think call affects me as much as most people, and I'm pretty sure I'd rather do that than work all these extra weeks and weekends that I do now, but it would be a change with some risk.  I don't really want to do administrative work.