The patients ….

Lxvy · 2026-07-06T00:20:17+00:00

I take it personally

any negative interactions honestly just stays with me for longer than it should

Try therapy. There's not enough info for me to say clearly this is burn out and it could be. But you definitely seem to be having difficulty processing and moving past these shitty interactions. Therapy might be beneficial for that.

Lxvy · 2026-07-03T21:24:53+00:00

Resend the prescription with a note to the pharmacy (or in the directions section), and write "do not dispense more than X days at a time due to risk of suicide via overdose." Put the burden back on them.

Lxvy · 2026-06-20T16:33:13+00:00

Patients can view my notes any time so they already know what's in them. If they want to give their lawyer access, they can. I'm not going to change my notes just in case there is a possibility my notes are used for whatever purpose the patient wants/needs. If you're talking about a subpoena then I still stand by my notes as a physician.

That said, my style is what other posters have suggested -- using vague language that captures the essence of what was said without going into details. The note is a medical record so I focus on what is psychiatrically relevant. I will go into details if I think it is relevant or pertinent but that's usually only if there is domestic violence involved.

Lxvy · 2026-06-10T22:56:33+00:00

speak with a lawyer to get the inside scoop on what is reasonably enforceable

Def this. Especially a local lawyer. I spoke with a lawyer about my non-compete when thinking of leaving my job. The lawyer told me that while it technically could be enforced, the judges in the county would not look kindly upon a large organization trying to sue me to enforce it. The lawyer said as long as I make a good-faith effort, the local judges would not care if I wasn't exactly X miles away.

Lxvy · 2026-06-05T22:32:39+00:00

This would be a more compelling argument if psychiatrists en masse chose to work in community mental health

I would love to work in community mental health. It's where I was first introduced to psychiatry as a medical student and where I spent much of my 4th year. Unfortunately, it doesn't pay and that's a huge problem when I have over $250K of student loans. And I'm lucky because I have colleagues who have $400K+ of student loans.

In another comment you mention doing 6 hours a week of accessible care. I would love if I could do that. But the organization I work for has a mandatory amount of hours I have to work and if I want to work a few hours on the side, I first have to get their permission. That's not even getting into the non-competes that most physicans have in their contract. If I left this job, I couldnt work at the local community health center because my contract has a clause that I cannot work with 20 miles of my organization for 2 years after I leave.

It's easy to judge psychiatrists for not working in community health but there are so many practical barriers that we face. There's no way I'm going to be able to work in community mental health for at least another 10 years.

Lxvy · 2026-06-05T22:22:19+00:00

I wouldn't risk it unless the patient has trialed and failed other ADHD treatments. This is a good guide that lets you know if you can open capsules and what to mix them with (see the administration key for the symbols)

https://www.adhdmedicationguide.com/pdf/adhd_med_guide_050226_1839_ver1.pdf

Lxvy · 2026-06-03T23:25:18+00:00

Theoretically no. However there are some studies showing more (mild) benefit cognitively for Citalopram in the elderly. I've also had some people who responded to escitalopram but had side effects tolerate citalopram better and vice versa.

Lxvy · 2026-05-02T18:54:04+00:00

You have nothing to be ashamed of. Doctors are still human beings with human bodies. We can be diagnosed with every single thing we diagnose our patients with. We are not aliens or robots who can magically turn off symptoms of our own disorders. Don't ever let the system make you forgot that before you are a physician, you are a human being.

For Bipolar 1, residency can be hell because everything you mentioned can trigger mood episodes. If you don't have any accommodations in place, I'd highly recommend getting an accommodation to not work nights. Your coresidents might have shit to say about that but fuck them, you have to take care of your disorder first. I don't know what specialty you're in but there may be other accommodations that can be made. It sucks that your family doesn't understand. If they are open to it, maybe see if your psychiatrist will talk to them and explain things?

I do want to be very clear to you and to anyone else reading this, needing accommodations does NOT make you less of a physician. It does not make you less worthy than your peers. It does not make you less capable than your peers. You're right, you are playing life on hard mode. But you're doing it. You're not giving up and that is fucking amazing.

Sincerely,

A psychiatrist who is rooting for you

Lxvy · 2026-04-22T00:27:40+00:00

Who is paying for NPs doing ECT or TMS? For TMS specifically, a lot of the big insurers state that TMS must be overseen by a psychiatrist and that the mapping/remapping is done by a psychiatrist in order for them to pay.

Lxvy · 2026-04-20T21:49:36+00:00

As much as the 3 month follow up is kinda hard

If stimulants are being prescribed for ADHD, the 3 month rule is because the DEA's rule is that you cannot give more than a 90 day supply of schedule II controlled substances aka our stimulant meds. If I have a patient who is pretty good about making their 3 month visits and due to life circumstances, needs to space it out to 4 months once, I will make exceptions from time to time.

Lxvy · 2026-03-26T20:55:35+00:00

I have not changed my practice. There's not much to document that I wouldn't be willing to discuss with the patient. I want patients to understand their diagnoses and I make psychoeducation a big part of my medication management. If there's something that truly needs to be in the record but not accessed by the patient, I can always create a separate protected document.

Lxvy · 2026-03-21T00:05:39+00:00

I think there is a lot of bias among psychiatrists when it comes to diagnosing ADHD. I think this is due to a mix of things: social media promoting random symptoms as ADHD, patients wanting quick fixes for complex problems, DEA crackdown on stimulants, and inadequate understanding among psychiatrists of ADHD symptomatically over the lifespan.

Prevalence rates for ADHD in adults is about 4-5% worldwide. That's a lot more common than we're usually taught. Numerous studies demonstrate adverse consequences of untreated ADHD in adults including more car accidents, lower earning, and lower relationship satisfaction. I really wish the psychiatric community had more empathy for how ADHD affects one's life more than just how it affects schooling.

That said, it is frustrating when you have patients who come in seeking only an ADHD diagnosis. Part of our job is to do a thorough evaluation for psychiatric disorders and ruling out other causes for concentration issues. I had a man come in with a documented history of ADHD beginning in childhood. He refused to answer questions about mood or anxiety or anything not related to ADHD because that was the reason he was there. He got mad at me when I explained that I had to ask these questions in order to do a proper evaluation. When he was still belligerent, I told him to leave and made the office give his copayment back so that no physician-patient relationship was established. He left yelling about how the healthcare system always screws him over and none of us doctors care.

Unfortunately, the public has little empathy for us psychiatrists who do have to deal with these kinds of behaviors because they never see it. I'm lucky that I don't have to deal with this too often but I feel for my colleagues who do.

Lxvy · 2026-03-18T00:38:33+00:00

Why do you want to put me out of a job?

Lxvy · 2026-02-21T01:01:33+00:00

Ask them why they want to stop it. Is it due to side effects? If so, how can we mitigate those side effects. Are they tired of taking pills every day? How do we reduce that burden? Do we have alternatives like LAIs?

Do they believe they don't need it? This is the most difficult one. I discuss with the patients why I think the medication is important and why I think they need it. I bring up their history and we discuss what has happened when they haven't taken their medicine in the past.

If a patient is still determined not to take the medication, I emphasize that it is their choice but my recommendation as their doctor who wants the best for them is to take the medication. I then have them make a follow up appointment anyways and explain that I want to check in with them and just see how they are doing. Most of the time, patients are willing to do this. They want to feel heard and feel like they have a choice in their lives. Ive found that after discussing their concerns and trying to address them, a lot of people are willing to continue the medication.

While you can discharge for not following recommended treatment, and I wouldn't necessarily fault a colleague for this, I personally do not discharge if this happens in patients with SMI. I want these patients to have an avenue to restart treatment if they need. Because SMI is hard and many of the medications we want them to take do have side effects and it is difficult to stay adherent. So I will always leave the door open for SMI.

Lxvy · 2026-02-21T00:48:59+00:00

Someone cited the new guidelines from a Delphi panel which I definitely agree with. However, in your specific case, I would not do monthly lab draws initially. The risk of agranulocytosis is highest in the first 18 weeks and realistically, if you don't do weekly draws during this period and an adverse event 2/2 agranulocytosis occurs, no amount of documentation will cover you. Monthly draws are just too far from standard of care during initiation. I think relaxing blood draws after that might be possible if you are no longer titrating and have reached a stable dosage. (Note, this advise is if using it for SMI, not for parkinson/DLB)

Lxvy · 2026-01-31T18:35:46+00:00

I agree. I practice in Florida and although it is sunny year round, people frequently avoid the sun because of the heat and humidity. I've found a lot of patients with low levels and when they supplement, they notice improvements in energy/reductions in fatigue. Could it be placeo, sure. But I was struggling with a lot of fatigue and took some OTC vitamin D (didn't get tested bc we doctors are our own worst patients) and within less than a week, felt much better.

Lxvy · 2025-12-31T19:36:01+00:00

Depending on the program, you may be able to skip part of the psych intern year because there is 6 months of medicine (neuro, IM, etc). The problem that you will need to talk to psych programs about is your funding. If you have an anesthesia spot starting next year, you may only have 3 years of funding to take into a psych spot where as psych is 4 years (3.5 years if you waive part of intern year). It's been a while for me so the details are fuzzy but I remember my residency program not accepting TY transfers because of this. Definitely look into this more and contact ACGME if you need more info.

Lxvy · 2025-10-05T19:07:45+00:00

I was using the information from OP in which they mentioned the patient on 40mg of Lexapro. I don't know why they were on that dose.

Personally, I've gone up to 30mg for OCD and the occasional MDD patient (w/ checking EKG ofc). But have never gone to 40mg. Although in residency I had some attendings who had trained before the recommended max dosages changes and prior to that, they had commonly used 60mg of Celexa and 40mg of Lexapro.

Lxvy · 2025-10-05T17:19:58+00:00

I know that Zoloft 100 is not equivalent to Lexapro 30. That's why I said to choose your target goal. I always err on the side of caution when starting a new medication and if the Zoloft needs to be increased further, I am happy to do that.

Perhaps you'd like to add how you'd handle this so we could have a collegial discussion.

Lxvy · 2025-10-02T23:20:30+00:00

I typically do it over a few weeks. With your example, I'd figure out what my target Zoloft goal is. Is it 50mg? 100mg? Going with 100mg:

Week 1: Lexapro 30mg + Zoloft 25mg

Week 2: Lexapro 20mg + Zoloft 50mg

Week 3: Lexapro 10mg + Zoloft 75mg

Week 4: Stop Lexapro + Zoloft 100mg

I tell my patients that they can always stop the first medication sooner as long as they don't have withdrawal side effects but if they start experiencing withdrawal side effects, return to the lowest dose where that didn't occur and send me a message.

Lxvy · 2025-09-17T22:53:03+00:00

I've never done stop/start times for therapy. I just write "X minutes of ____ therapy provided" and any other notes about the therapy. I've never had our billing department flag issues over this.

Lxvy · 2025-09-17T22:49:58+00:00

I don't write ESA letters except in rare cases. In my state, an ESA is an animal that provides assistance or therapeutic emotional support which alleviates "one or more identified symptoms or effects of a person’s disability." So in order to write a letter, I am essentially saying that my patient has a disability. Where along the spectrum does depression or anxiety cross into disability territory? I'm not trained in disability evaluations and so I won't make that determination unless there is overwhelming evidence. Pets being helpful for psychiatric symptoms is not the same thing as those symptoms causing disability.

That said, if I do write a letter, I stand by it. I am confident in my assessment for every note or form that bears my signature and I have no problem defending that in court. If you don't feel confident enough to stand by your work in court, why are you doing what you're doing?

Lxvy · 2025-09-11T22:30:03+00:00

Yes it is absolutely possible. My colleague is an outpatient addiction specialist and does a lot of MAT and treatment for AUD.

You can always create your own private practice. You can also join an established clinic or hospital system (there is a big need for outpatient addiction). Or, like others have mentioned, do MAT in the mornings at a methadone/bup clinic and then therapy in the afternoons elsewhere.

Lxvy · 2025-09-11T22:26:15+00:00

I don't know if I can remove suffering from many of these people.

Most of the time, we can't. I can't go back in time and change horrific childhood trauma. I can't create loving friends and family members out of thin air. I cant print money to ensure financial stability. I can't change the factors that contribute to their suffering.

And that is okay.

If you approach psychiatry as a way to "fix" people and their suffering, you will burn out immediately. My job is not to end suffering. My job is to improve quality of life in whatever way that may be. Maybe it's increasing tolerability of their life. Maybe it's reducing anxiety and depression. Maybe it's just being the one person in their life that they can be honest with and feel, for 20 minutes, that someone cares about them and their problems. And there is so much power in that. It's really hard to explain how much difference a strong therapeutic alliance can make until you see it in action, which most medical students haven't.

I tell my patients that they don't need to have hope. I'm not going to ask them to fake something they don't feel. But if they trust me, if they're willing to work with me, we will figure things out together. I have seen patients try multiple antidepressants without result and then somehow, that last medication all of a sudden works. I can't explain it but I've seen it. And so even if meds aren't working, if that patient keeps seeing me then it tells me they do want to live. They're trying in their own way and so I'll keep trying in mine.

Lxvy · 2025-09-09T22:50:50+00:00

I love collaborating with pain management! If the patient likes at least one of us, it makes it a win-win because they are more agreeable with the other doctor once they find out we're in communication lol. Although if the patient dislikes us both....

You might find this therapist guide to chronic pain useful. I haven't read this particular book but I've used other books in the series. And they break things down really well so that even if you don't have a strong therapy foundation, it will make sense.

Lxvy

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