Resident here trying to wrap my head around how private practices work. I have heard that many clinicians avoid accumulating too many acute patients inappropriate for their level of care/practice style via screeners and other methods…but then what? How do you do this ethically? Is this even possible to do ethically?

1. What were your expectations?

2. What was the reality?

3. Are you comfortable and content based on this?

I’m curious if anyone has listened to this latest episode featuring anti psychiatry advocate, Laura Delano? I know she’s been discussed previously in this subreddit.

I listened to the whole episode last night. I”ll start by saying that I’m not a Theo fan. I tune in occasionally to stay in touch with current media and/or when someone interesting is on. Several times throughout the episode she made clear to say that she wasn’t a doctor, while at the same time, giving what sounded like very clear medical advice (de-prescribing guidelines and naming specific medications with specific deprescribing guidelines attached). Specifically with Theo, she was assisting him in his taper of Escitalopram because he was having a hard time. Obviously, this is very suspicious. What I found really interesting was that in this entire podcast she refers only to receiving one diagnosis throughout her time as a psych patient (Bipolar Disorder). She discusses her many hospitalizations, suicide attempts, failed psychotherapies, dozens of failed medications. Touches only briefly on her chronic alcoholism and drug use. However, there’s an early New Yorker article she wrote several years ago that mentions she also received a Borderline Personality Disorder Dx. Perhaps her book mentions this, but I thought this was an interesting omission on her part to exclude from the podcast.

Another interesting tidbit from the episode is her work with MAHA and who she references as Bobby Kennedy. She outlined the framework they are putting out there toward guidelines around deprescribing. When discussing this, she was very certain to point out that the administration was not trying to take people’s psych meds away.

One last thing…. Probably the most alarming thing she said was that physicians were not adequately trained in deprescribing. That they were getting people hooked on medications without having an exit strategy. It all sounded very dire. She presented her de-prescribing method as much superior. Obviously, the ramifications of this content and misinformation don’t need to be spelled out. Theo’s audience is massive, especially the young demographic.

So I’m curious what people’s thoughts are on her and on this anti-psychiatry/anti-medication movement and why it seems to be gaining traction?

Edited last part of question.

A 55-year-old patient presents for evaluation of cognitive and behavioral changes over the past three years. They have become impulsive and rude and lost their job for failure to meet project deadlines. Patient's found sitting at the computer workstation says, quote, I've been waiting so long for you, I figured I would go ahead and do your job for you, exclamation point, and later grabs a reflex hammer and says, now it's my turn. Which cognitive test would most likely be affected by this patient's disease? A, recall, B, language, C, orientation, or D, object naming. Why is B the answer

Hello,

Currently PGY4 interviewing in person for a dream job (in a competitive locale) - inpatient/forensics role. This being my first interview for a job, I am kinda nervous although I realize that it is not meant to be as high stakes as a residency interview. Largely because I really want this job.

Any recommendations on how to prepare? What kind of questions do they generally ask?

Thanks for the help!

I am working inpatient and have a little over a year left to achieve the number of payments for PSLF. I just simply cannot do it. I am so burned out. I am getting tired of the thankless work, acuity, and so many other things. Any suggestions on what I should do- do I just stick around for another year? I wish there was some sort of telepsych work from home gig that was PSLF eligible. My work is turning me into a grumpy cynical human and I hate who I’m becoming. I don’t feel well supported at my job, feel it is dangerous, social workers are straight out of school seemingly with something to prove, nursing turnover is constant. I can compile a never ending list. I just want out, for my own sake and my family’s. Any guidance on what I should do?

Taken from the residency sub.

Whether it has faded or not, how do you feel about your day-to-day now?

I’m a PGY-2 and I feel behind in my fund of knowledge, especially with psychopharm and recalling DSM criteria.

I study and have read the DSM-5 multiple times, but I struggle to retain information and often go blank when presenting to attendings or trying to explain my differential or medication choices.

I work hard, finish my tasks and notes on time, and try to be a good co-resident. I’m not lazy, but I’m exhausted by the end of the day and feel burned out. I’m also worried that these knowledge gaps could affect my performance in residency.

For those who struggled with this in the residency, what actually helped u improve your clinical knowledge and recall w/o spending hours rereading textbooks?

Rules:
I will not respond to unconstructive feedback or questions.
No political Dogma. 
A future plan would be necessary to increase Medicare and Medicaid payments as incentives.
A separate future plan would need to repair wage rate to productivity. 

Necessary background information to understand the plan:
Between employee and employer families are paying roughly $10,000 to $25,000 a year and are getting less coverage each year with increasing premiums each year.
Insurance companies are making record-breaking profits.
Administrative services spends roughly 40% of every Healthcare dollar that is spent.
Elimination of billing overhead would significantly reduce cost.
The current system is unsustainable in the long-term. 
The plan would allow someone in an emergency to not worry about emergency room coverage as that medical condition would be covered.
This plan does not change Medicare or Medicaid.
You are not able to search for better medical rates in an emergency situation.
Billing coding departments would be significantly reduced therefore less cost.
Prior authorization practices would not exist.
Administrative time wasted on the phone to receive payment from the insurance company would not exist.
Reduced office staff.
Clinics would be able to reduce the rates they charge because they're overhead cost has significantly reduced. 
Costs of prescription medications would reduce because of the elimination of PBMs.
Insurance companies are likely to flip to selling chronic condition coverage or catastrophic illness coverage.
General Medical Care would be a direct payment system as it is much more simplistic and cheaper to establish and run.
Individuals or families wanting to hedge risk against a chronic or catastrophic condition would have the opportunity to purchase such a policy. Policies would most likely be much cheaper than the current system.
Cost savings would then be used for whatever the person needed to spend it on or perhaps a protection policy.
The emergency room system is the gatekeeper of establishing if something should be designated as an emergency situation and should be covered.
If a questionable emergency situation needs to contact the emergency room nurse triage line.
If arriving at the emergency room and has not contacted the nurse triage line would then be triaged at the emergency room and shifted to urgent care for that not be an emergency.
If later decided that the urgent situation is actually an emergency would then be covered under the emergency protection.

Pros:
Significantly reduces overall cost
Reduces administrative waste
Eliminates unnecessary complications
Provides emergency care for all citizens
Everyone will be able to see rates for Primary Care and other services around them 

Cons:
The insurance industry would have massive layoffs
Retirement funds would take a massive hit if invested in insurance companies
Billionaire class would likely try to prevent
Massive layoffs with billing industry
Increased pressure in the emergency room to designate something as an emergency

Plan:

Phase 1: Legislative and Tax Foundation (Years 1–2)

·        Subsidize and Expand Farming in the USA: Reduce costs of healthy and natural foods to be affordable.

·        Pass the Emergency Care Act: Establish the Universal Emergency Fund and legally define "emergent condition" using existing EMTALA clinical frameworks.

·        Establish the National Nurse Triage Line (1-811): Legislate a federally funded, toll-free medical advisory line staffed by licensed RNs using standardized clinical triage protocols (e.g., Schmitt-Thompson protocols).

·        Enact the Federal Emergency Payroll Tax: Implement the 6% to 8% payroll tax to fund both the emergency care pool and the 1-811 infrastructure.

·        Create Regional Fee Schedules: Set fixed government reimbursement rates for emergency services based on Medicare Diagnosis-Related Groups (DRGs).

·        Mandate Price Transparency: Require all providers to publish binding cash prices for routine, non-emergent care online.

Phase 2: Insurance Deconstruction and Re-Regulation (Year 3)

·        Wind Down Comprehensive Insurance: Ban the sale of traditional, employer-sponsored comprehensive health insurance plans.

·        Launch the Catastrophic Add-On Market: Introduce regulated "Catastrophic & Chronic Care" insurance riders with a national reinsurance backstop for pre-existing conditions.

·        Ban PBM Rebates: Eliminate Pharmacy Benefit Manager (PBM) hidden rebate structures to force direct-to-consumer cash pricing on pharmaceuticals.

·        Build 1-811 Infrastructure: Hire and onboard thousands of remote RNs. Integrate the triage line with local EMS dispatch systems and a directory of transparent, direct-pay urgent care and primary care clinics.

Phase 3: Systemic Transition and Hospital Restructuring (Year 4)

·        Launch 1-811 Public Campaign: Run a massive national public service campaign ("Call 811 Before You Go") to educate citizens on using the nurse line to avoid out-of-pocket ED bills.

·        Liquidate Billing Overhead: Hospitals dismantle insurance-negotiation departments and shift resources to direct financial counseling for non-emergent walk-ins.

·        Open the Direct Primary Care (DPC) Market: Standardize state licensing to allow primary care doctors to easily transition to cash-pay, monthly subscription models.

·        Activate ED Triage and Safe Harbors: Implement the new ED gatekeeping workflows. Pass legal protections shielding ED doctors from liability when they deny emergency classification to a patient based on standard medical guidelines.

Phase 4: Full Deployment and Optimization (Year 5)

·        Go-Live: The Universal Emergency Fund becomes the sole payer for emergency room visits nationwide.

·        Implement the 1-811 Accountability Loop:

o   If 1-811 directs a patient to the ED, the visit is automatically fast-tracked for Universal Fund approval, reducing the hospital's administrative audit burden.

o   If a patient bypasses 1-811 for a non-emergent issue, they are greeted at the ED triage desk with a choice: proceed and risk a personal cash bill, or use an on-site 1-811 kiosk to redirect to an affordable direct-pay clinic.

·        Evaluate Behavioral Trends: Deploy federal auditors to monitor hospital compliance with cash pricing and assess ED utilization rates to continuously optimize nurse staffing levels on the 1-811 line.

Used BTB, went through qbnak twice, halfway through videos. How useful are the videos? Is BTB enough?

Hi! GP registrar here. You often hear about certain SSRI (I.e. fluoxetine) being more activating, some less so (citalopram, escitalopram), maybe sertraline somewhere in there middle. I tried to find evidence in regards to this but it seems to be mostly informed by clinical experience. In practice, how significant do you tend to find these differences to be?
Specifically looking at sertraline, wondering if a medication change is a better option for a patient, given higher doses of sertraline haven't been tolerated due to agitation/tension. Thank you

Feeling especially fed up and a bit helpless recently with the ongoing high profile court case noise in the background and being immersed in the horrific mental health system around me. As with numerous other social topics, this country refuses to learn from it's mistakes and tragedies. Would like to vent about our local system of involuntary holds, which is pretty much non-existent. Our average LOS in the hospital is about 48 hours as that is all the time you have before the state will drop a hold, if you are lucky. Today dealing with an individual that has threatened to kill his family, has been petitioned twice and didn't even make it an hour in the emergency room without the hold being dropped. Other common occurrences: Attempt suicide and end up in the ICU on the vent? Hold will be dropped as soon as the vent is removed and you can mumble the words "I'm not suicidal." Most of these patients never even make it to inpatient psych and no treatment is even started. Put a gun against your head in front of witnesses and police? Hold dropped. Become so psychotic a SAR mission is required to find you in the forest? Hold dropped. Have severe malnourishment because your MDD is so bad you're wasting away? Hold dropped. We are not even allowed to give involuntary psychotropics in our hospital the current time as our hospital legal department has barred us due to failures of legislation that allow lawsuit against the hospital for administration of involuntary LAIs no matter the circumstances of if it was approved by a mental health judge. It's totally insane. Honestly, the only mental health care we have locally is if you have mild depression and anxiety and you actively will go out of your way to get help.

Things we've tried: meetings with the evaluators of involuntary holds. Inviting these evaluators to patient care meetings. Reporting evaluators to their government supervisors. Our hospital actively petitioning local legislators to change the laws (in the past year they declined to work on this as it was an election year and not a priority).

Thanks for listening. /End Rant

Passed boards in 2023 and my first cycle is almost up. Any advice on these article quizzes? They’re open book and you have to get 4/5 correct right? Are they particularly tricky? Any tips?

Stating this as a shrink who has helped his patients in different roles spanning IP, OP, ECT, TMS, Esketamine, different psychotherapies and prayers.

Edit- although I appreciate the reactive and some reflective responses this post is not just the true layperson’s reality but a reminder to us that we cannot remain sitting on our hands and have to keep advocating for better treatments and treatment outcomes from ourselves and our psychiatry community at large.

Is there any type of prompting that is more attention grabbing than Board Vitals for questions that require multiple answers? I miss them every time bc I just autopilot select the one I think is best. I’ve been doing these questions for weeks now and still keep doing it

Hi, I work as an addiction psychiatrist in the New York area and I have a patient who lives in north Jersey. He has been having issues with suboxone compliance so wanted to look into sublocade.I realize it is a little unorthodox but given the fact that he’s been doing well on suboxone I thought it was a reasonable idea. When we found a place that does give sublocade, he was denied because kratom does not count as opioid use disorder and they were hesitant on using sublocade in general for pure kratom use.

I’m just curious what the consensus is on this, I order sublocade for clear opioid use disorder but I honestly don’t have a lot of kratom patients. My one other patient I see is on vivitrol which has been working with him. Is sublocade not a good option?

In my opinion, if a patient comes in inquiring about possible autism, but mental status exam is normal, then that patient (almost without exception) does not have ASD.

To clarify, when I say "normal" that specifically focuses on eye contact, thought process, speech, and behavior such as nonverbal communication, movements and recognizing personal space.

Edit: since this has sparked some good convo, wanted to add some context/thoughts.

- I stated it this bluntly to make a point/spark conversation. What I am trying to point to is that, at some point in their treatment course, I expect to see some objective impact/evidence of their ASD in my appointments if it is real.

- I am a child psychiatrist, but have run into these questions with both adults and children.

- In my mind, autism is, at its core, a communication disorder. If people are not having communication deficits, then they do not meet criteria, though they may have some traits. Do you all share this view, or am I misguided?

- People have commented regarding the wide spectrum of ASD, and not all ASD looks like level 3, nonverbal. I guess this is one of my points/questions... At what point does a difference of degree become a difference of kind? In other words, should a generally successful adult who struggles a bit with group social interactions and has some niche interests REALLY have the same DSM diagnostic label as my 14 year old patient that spends 13 hours each day rewatching the same 30 second clip of SpongeBob?

- I also would love input from folks about the various levels. When you read "requiring support" (level 1), "requiring substantial support” (level 2) and "requiring very substantial support" (level 3) per DSM5, what do those descriptions mean/look like?

Curious if anyone has some suggestions for approaching the topic of pay raises when working as an inpatient medical director for a pseudo private equity academic position?

I have an RVU based compensation model with a fairly low but common conversion factor of 52$ for our region. That more or less constitutes the entirety of my pay, other than stipend as a medical director at 150$ per hour but the hour cap is 20 per month, which I vastly exceed as I supervise 1-2 residents and 3-6 medical students per month and have endless meetings. There is no compensation for night call which is constantly changing as the organization shuffles around providers.

I see numerous avenues I could approach for asking for more compensation, but generally the organizations approach is just work more make more, which truly only serves them. Despite the particulars, my job is highly sought after and they could easily replace me which I feel hurts my bargaining power.

Should I just continue to work harder and enjoy the gig, or is it worth it to pressure for changes to compensation once contract renewal comes up? I like the job and do not have any true intention of leaving, but I have learned nothing will change if I don’t ask.

I know for adult boards, prites are considered lower yield. Is this the same for child? is it worth studying the old ones? any other particular recommendations?

I have a mix of older & newer PRITES, but particularly looking for 2023 & 2025! Much appreciated!!

I've been trying to pick an EHR for my small practice for what feels like months now and I'm honestly at the end of my rope. Every demo promises the world, then you find out billing is an add-on, e-prescribing is another add-on, and the "simple" note templates need a paid consultant just to set up. I spent a whole weekend comparing pricing tiers and still couldn't tell you what any of these will actually cost me over a year. It's wild that something we're basically required to use is this confusing and this expensive for a solo doc who just wants to see patients and write notes without fighting the software. Am I the only one who feels like choosing an EHR is somehow harder than residency? How did the rest of you small practice folks actually land on one?

I utilized the BoardVitals QBank for ABPN Board Prep in 2023 and really liked it. I didn’t claim these CME credits for ABPN board cert because the activity predated my current 3-year block.

I was hoping to utilize BoardVitals’ Psychiatry CME QBank to wrap up my CME for my current 3-year block. I have been having difficulty purchasing the ‘Psychiatry CC 6 month with CME’ QBank when logged in to BoardVitals with the same account that I utilized for board prep. I called customer support and they indicated that “you can’t have two subscriptions for CME products within the same specialty with the same account” and suggested that I create a new account utilizing a different email address. This feels fishy to me, but maybe I’m over thinking it. Anyone else have the same problem and use BoardVitals’ suggested workaround?

Additionally, any recommendations for alternate QBanks that give CME?

I see patients aged 14+ at an outpatient FQHC primary care clinic am really considering declining intakes that are purely ADHD assessments for patients who are aged 19+. Out of the 16 intakes I have done so far for the week, 11 were adult adhd and it is exhausting.

Nobody else at my clinic has had a refusal for certain dx… Has anyone else refused adhd intakes? What did that look like for you?

Why am I over here missing inpatient SPMI, that is crazy 😭

UPDATE for confusion: I am a psych NP with years of experience and I work in a PCP office because the county does not have funding for more psychiatry clinics. Medicaid patients cannot go outside of the county for psych care per Medicaid rules so they have to see a PMHNP at a PCP clinic for “consulting.” In rural America it is called “integrative care”. Medicaid does not pay for neuropsych testing so patients don’t have that option either.

I’m officially 10 days out from the ABPN Psychiatry boards and starting to panic a little about how I’m using the time I have left.

My biggest problem with studying has always been resource overload. I have a really hard time committing to just 1–2 resources because I constantly worry that I’m missing something important somewhere else. Then I end up jumping between resources and probably wasting more time than if I had just stuck with one.

For the past 2–3 days, I tried incorporating the Beat the Boards videos, thinking they would give me a condensed/high-yield review. Unfortunately, I’m finding some of them incredibly time-consuming for what I’m actually getting out of them.

The Substance Use Disorders section especially frustrated me. I went into it hoping for a focused review of things that are likely to show up on the boards, but so much time seemed to be spent discussing individual research studies, data, and background information. With only 10 days left, I kept thinking, Is this really what I should be spending my time learning right now?

For those who have recently taken the ABPN general psychiatry boards:

• Did anyone else feel like the Beat the Boards videos were not a good use of time this close to the exam?
• Are there specific BTB lectures that actually ARE worth watching and are particularly high-yield? Neuro? Psychopharm? Child? Statistics? Sleep?
• Are there any lectures from another resource that are much more board-focused and condensed?
• If you only had 10 days left, would you forget lectures altogether and focus almost entirely on questions?
• Between Kenny & Spiegel, Ninja PRITE and BTB, what would you prioritize at this point?
• What topics would you absolutely make sure to review during the final week?

I’m not looking to learn psychiatry from scratch at this point. I really just need something that says: “These are the concepts you need to know for this exam, these are the ways they test them, and these are the things you’re likely to confuse.”

I would especially appreciate advice from people who have taken the boards in the last 1–3 years, since you actually know what the current exam feels like.

At this point I need to stop collecting resources and commit to a plan for these final 10 days. 😭

If you had 10 days left, what would you do?

I am newly diagnosed with a fairly benign (obs don’t mean literally!) cancer. Will be getting surgery and radiation. Will obviously take time off for surgery. But what are your thoughts on taking time off for radiation? I haven’t met with my radiation doctor yet. But I hear that most people don’t take time off for this. But I also hear that it can really affect you cognitively and energy-wise. And I don’t really feel safe caring for patients under those conditions. Would it be outrageous to request those four weeks off? I know that as long as my doctor is willing to fill out the forms that I am entitled to it and don’t even need to divulge to my employer the specifics. But I kinda feel weird about requesting it from the radiation doctor to begin with when everything I hear is people working through it.

Hi! I'm a current chief resident at one of the Ivies, with a strong focus on inpatient/emergency psychiatry, an interest in resident education, and plans to do part-time private practice. Does anyone have any insight into how the job market is within NYC/Philadelpha/Chicago, particular systems they really enjoy/loathe working for, or general advice in locating roles that balance compensation with leadership opportunities? Thank you!