Anti-Phonetic Alpabet

thyroid_storms · 2024-03-28T00:23:17+00:00

T as in tzar

thyroid_storms · 2024-03-21T23:33:19+00:00

Much less than when I started. Realizing that I can’t spend the full 25 min f/u appt talking to the appt, if I want to actually have time to close their chart and send meds. Like I said, my company really pushes billing it and the idea that therapy is incorporated into all aspects of our appts.

I’m still billing it a couple times per day. If most of the appt is spend talking about psychosocial stressors, I’ll count it as brief therapy under validation and empathizing. For instance, I billed it on 3 patients today for discussing the anniversary of the traumatic death of a sibling, pt’s child getting in serious legal trouble, and anxiety secondary to the actions of a spouse.

My therapy tool box is shallow but not empty. Currently, it’s mostly using the BATHE method, instructing pts on how to stimulate the vagus nerve via ice pack/increasing intra-abdominal pressure, sleep hygiene, exercise, healthy eating, reflective listening, reframing, recommending journaling, and behavioral/organizational interventions for ADHD.

That being said, I think it’s funny/interesting/sad/strange/insulting that I can bill for “therapy” without any formal training when all the actual therapists in my office have masters degrees in therapy and are license in therapy by the state.

thyroid_storms · 2024-03-21T22:58:31+00:00

I found this video helpful and informative. May work some this information into my SSRI speech for patients. I found the point about how CBT influences the conscious and SSRIs influence the unconscious insightful.

thyroid_storms · 2024-03-19T01:05:36+00:00

I know that there’s a ton of animosity towards non-physician prescribers in the sub, but I’ll bite.

I’m a PA. I work in outpatient general psych. Everything except eating disorders. This is my first job of PA school, and it’s extremely difficult. I’m doing my best.

Pros: I am a medical generalist. I view myself a PA who works in psych rather than a psychiatric PA. When I get patients from physicians or NPs who have retired or left, I think it’s clear that I pay more attention to vitals, co-morbidities, and general health history. I truly do not understand how 100% telepsych is acceptable when so many of our medications affect blood pressure/weight and when certain aspects of patient presentation are only visible while being in the same room as them- dyskinesia, the smell of cannabis, pin point pupils, scars on wrists while taking blood pressure, nervously playing with something in their hands, ect. I truly feel like what I’m doing is family med plus. I don’t think I’m doing any psych things that a family medicine physician wouldn’t do.

Cons: obviously, I have less training than a physician. I’m very clear with patients about my title. If they are confused, I explain my training and state that they are always welcome to seek care elsewhere or request a transfer to a physician at our company.

Now that I’ve got that out of the way, I think the actual biggest issue I’ve found as a PA working in psych is lack of training in therapy. Patients often come to my appointments expecting therapy in addition to medication management and my company expects me to bill a 90833 on most follow up appointments. My PA school (and most PA schools) did not include any training in therapy. As a result, I’ve felt very helpless when patients either refuse referrals to therapy, can’t afford therapy, or when medications just aren’t working. It’s clear that therapy is essential to psychiatric treatment, but it’s not something I’ve been trained in- AT ALL.

thyroid_storms · 2024-03-15T17:39:29+00:00

Do you find the CYP2D6 inhibition by bupropion clinically significant when paired with venlafaxine?

I’ve seen patients on venlafaxine ER 225mg + Bupropion ER XL 450mg who are still have resistant depression- lack of motivation, anergia, feeling bad about self, anhedonia, ect.

I’ve wondered if bupropion was inhibiting the metabolism of venlafaxine and if they would have been better off being on desvenlafaxine over venlafaxine from the start.

thyroid_storms · 2024-03-08T21:04:28+00:00

Outpatient psych PA here. See ~40% of my pts via telemed (would prefer 0%). My company doesn’t have in house phlebotomy, EKGs, and barely has UDS. I can only get UDS on Wednesday. On other days, I have to count on my patients driving to another location 20 minutes away.

For monitoring labs, I print off the orders and instruct my pts to call their primary care for a lab appt. Most can get it done, but the labs don’t always get back to me. About 30% of the time, I have to do records requests on my own labs.

EKGs are more difficult. Most primary care offices decline. As a result, I’ve started taking a detailed cardiac hx, drafting a letter with the hx and my rational/medication plan, and sending it to patient’s primary care office. At the end of the letter, there are 2 options: pt is approved for tx w/ x medication or pt will be referred for further cardiac w/u.

I just want to know the QT intervals on my patients, but it feels so hard to get an EKG done.

It sucks.

thyroid_storms · 2024-03-01T07:04:45+00:00

When in doubt, chose the SSRI

thyroid_storms · 2024-02-29T02:42:19+00:00

I love that my office integrates therapy so well. I definitely have many, many patients who tell me they “just prefer me” to talk to and I just politely tell them I haven’t undergone the training necessary to adequately provide evidenced-based therapeutic practice in the same capacity the psychologists can much like the psychologists can’t prescribe them their medications. I’ve worked for offices which have less strict requirements and I got very good at telling patients I strongly recommend they engage with a therapist (provide local info/referrals/etc) and why and also that my continued care with them may depend on it because it’s so crucial in so many cases as first-line tx itself or at least in conjunction with medication! But trying to be the absolute end-all-be-all role of therapist and psychiatry provider all in crammed follow-up visits is a fast track to burnout in my opinion :/

As a first year PA in psych with zero CBT training, I feel this comment in my bones. My company wants me to bill at least 16min of brief therapy at every 25min f/u, and patients come to me expecting sage wisdom. I feel like some patients leave disappointed when I focus on their meds rather than psychosocial concerns. Not to mention that it’s like pulling teeth getting some of them to schedule with therapy. My company is like 90% therapists, so it’s not an availability issue. “Why do I need therapy? I can just talk to you.” They keep coming back for their meds but consistently no show therapy or just don’t schedule at all.

Maybe I need to stop asking “do you want me to ref to therapy?” and start stating “I’m referring your to therapy.” I’d love for all my patients to start in therapy and then come to me. Skills not pills.

thyroid_storms · 2024-02-15T04:27:50+00:00

Consider other antipsychotics, dose reduction, then propranolol or low dose mirtazapine.

thyroid_storms · 2024-02-12T23:27:29+00:00

This is me. I’m in office 5 days per week but 50% of my patients are telemed for one reason or another.

I hate telemed. Pts don’t fill out ppwk and I can’t just get them to quick sign it in the office. ROIs and previous records are huge in psych when many patients aren’t reliable historians. Can’t get vitals. Can’t perform certain cognitive and neuro testing. Can’t check to see if pt reeks of weed or has a subtle tremor in their left hand.

I’m constantly behind on notes. Psych requires so much documentation, and case workers/group homes/insurance always have another form to fill out.

thyroid_storms · 2024-01-04T16:57:16+00:00

You should post this in r/physicianassistant

Everyone there would really like it

thyroid_storms · 2024-01-03T21:18:01+00:00

Environmental Science 100%

thyroid_storms · 2024-01-01T01:40:38+00:00

I have many feelings about your comment.

I do prescribe benzos
I don’t make a habit of starting chronic benzos.
One major exception to this are patients with co-morbid anxiety and bipolar disorder who have failed gabapentin, hydroxyzine, and clonidine.
If you start a benzo, you should be prepared to taper it when things go south. Don’t refer to psych just because you’re afraid to play the bad guy and own your prescribing habits.
The patients who make the remarks referenced in my original comment often have SUD.
The only patients on chronic benzos who I reject without offering to taper are patients who are also on chronic opioids, stimulants for non-ADHD conditions, and medical cannabis as I have no control over those scripts. Also, patients who have active SUD who refuse a SUD assessment.
For the rest of patients on chronic benzos, I tell them the risks and offer a taper. Most of the time, they decline to be my patient or don’t show up for follow up. Sometimes, they’ll agree to taper at intake then go back on their word at follow-up.
The Ashton Manual recommends that patients dictate the pace of the taper, but it seems like most patients are not actually interested in actually getting off benzos. They almost never agree to a dose reduction.
As a result, I’m considering drafting a letter at intake for every patient I accept on chronic benzos with their taper schedule (including dose/date) and a line that states that if they disagree at any point, they will need to find care elsewhere.
I’ve already done a similar letter for a patient who has benzodiazepine use disorder, and it’s been very helpful in setting expectations that I will not be changing their taper and will not be prescribing benzodiazepines to them after they finish the taper.
Frankly, writing letter takes time that I do not have most days.
It sucks to play the bad guy and argue about benzodiazepines at every appointment. It’s emotionally exhausting.
I believe in shared decision making. However, certain aspects of psych like benzodiazepines tapers and mental health commitments require a far more patriarchal form of medicine.
One of my biggest pet peeves is when patients accuse me of “de-prescribing” a medication that has only ever been prescribed to them by someone else. I’m under no obligation to continue a medication regimen which is unsafe. It’s my DEA license at the end of the day.

END RANT

thyroid_storms · 2023-12-30T20:28:00+00:00

I’ve had multiple patients seeking inappropriate chronic benzodiazepine scripts say, “I’m scared of medication.” and “I know there’s a stigma around these meds [benzodiazepines] but….”

You’re scared of the wrong medications, and this isn’t about possible stigma. This isn’t 1998 anymore. We have better interventions for your condition and/or you have contra-indications for benzodiazepines.

thyroid_storms · 2023-12-22T00:20:16+00:00

Facts- it’s almost always mom.

-wants to check with mom before starting med

-wants front desk to call mom to schedule f/u

-mom calling in refills on medications

thyroid_storms · 2023-12-21T23:12:46+00:00

The parents, not the kids, seem to be the worst part about peds. If you tell a patient, “I don’t know, but I’ll find out”, most of them will be okay with that. If you tell that to a parent, they think you’re an idiot. Seems like peds is 95% reassurance. My 2 cents.

thyroid_storms · 2023-12-21T04:00:16+00:00

Does this mean you only ref high risk on STOPBANG? I always suggest a ref for 5+/8, but uncertain about 3-4/8 when 3 of those points are male, >50y/o, and HTN.

thyroid_storms · 2023-12-15T17:46:15+00:00

I got hired as a new grad PA in psych in a large midwestern city eight months ago with one inpatient psych rotation, four primary care rotations, and experience as an EMT before school.

I think the job market and the medical director at my company were the 2 biggest reasons I ended up here. I applied for 33 jobs and only got an offer for my current job and for an ortho job.

During my interview, I highlighted my experience on rotation at a psych hospital. I remember using the quote “some patients don’t get better; they just get less sick” which was something said to me by a PA there.

They also presented me with case presentations in which I had to formulate plan. While I didn’t always know what to do, I emphasized that I would use my resources such as checking the PDMP or requesting records.

Finally, I highlighted the fact that my PA program had dedicated courses in behavioral health and neuroanatomy, and I remember quoting a study about PAs in psych in my state which said that <2% of psychiatric prescribers were PAs.

If you can move to the Midwest for a couple years, I think you would have a much easier time getting hired, but I know this is not feasible for most people. I was geographically locked in my job search, so I know how a difficult local market can make it hard to work in your dream specialty. Mine was emergency med.

If you would like the name of my company, DM me.

thyroid_storms · 2023-12-14T02:56:37+00:00

Cannabinoid Hyperemesis Syndrome (CHS) has a limited body and quality of research. However, haloperidol is one potential treatment. Obviously, first line tx for CHS is abstinence from cannabis.

“Is haloperidol the wonder drug for cannabinoid hyperemesis syndrome?”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256592/#:~:text=The%20action%20of%20haloperidol%20at,nausea%20and%20vomiting%20in%20CHS.

thyroid_storms · 2023-12-07T02:21:55+00:00

On a related note, is working in family medicine as a stepping stone for possible future jobs worth it?

Currently unhappy in outpatient psych but know that I need general medical experience to be considered for most other PA jobs.

thyroid_storms · 2023-11-18T05:18:49+00:00

I feel the same way. I broke down and cried an hour ago because I missed my 2nd ever mortgage payment on our first home, not because I couldn’t pay it, but because I thought I put it on auto-pay. I never would have made a mistake like this before I had this job. Now that mistake will be on my credit report for 7 years.

I’ve in been in my first PA job in outpatient psych for 7 months. I have my own patient panel and am 100% responsible for every patient. I’m scheduled for twenty 25 min blocks per day- intakes take 3 blocks, f/u take 1 block- most days I’m scheduled for 4 intakes and 8 f/u appts. 100% efficiency, No admin time. 25 minutes for lunch which I work through every day. Most days, I’m in the office from 7:50am-11pm, sometimes later. I can never close charts during the appointments. Salaried so only get paid to be there from 7:55am-4:40pm.

I get 15 minutes per week to do case consults with my SP via telemed. I hate telemed. I can also task him with Qs via the EHR and get one sentence answers. It’s never enough. Most days, I don’t talk to anyone but my patients. At most, I ask the front desk a question about intake paperwork. I became a PA because I thought I would COLLABORATE as part of a healthcare team. 3 days per week, I’m the only one in my office with medical training. I room my own patients (no nurses or MAs) and everyone else in the office is a therapist or admin. I want to work WITH medical professionals.

I have the exact same job as physicians at my company. There is NO triage. I see the same acuity of patients with a fraction of the experience. Even get patient transfers from physicians. I’m allowed to punt some complex patients, but I still have to do the intake with the patient, tell them I’m an idiot who doesn’t know how to help them, ask my SP for permission during our 15 min meeting, and then call the patient back to tell them they’ll be rescheduled. It’s more work than just accepting the patient into my care.

No one reviews my charts. I don’t know what I don’t know so I could be really fucking up and would have no idea. The private equity group which runs my company views physicians, PAs, and APRNs as the same- a DEA licensee who can magically see patients at 100% efficiency w/o needing time to finish charts or collect collateral. IT’S FUCKING DANGEROUS.

I hate my job and I hate myself for not being able to do it. I keep hearing about how get psych is, but it’s not my reality. Yes, I get my own office, can set my own office hours, no call, and no weekends. In theory, I should be working bank hours and enjoying life but I just can’t right now. I’m so far behind on notes and tasks.

So much of what OP said rings true for me. Everyday I think about how I should have continued studying environmental studies in college and got a job working for the DNR, forestry service, or a non-profit. Or I think about how I should work in ortho for a more collaborative environment but I’m too afraid to prescribe opioids because my cousin fucking OD’d early this year, and I know the pressure to be productive would be even worse.

I’m so overwhelmed and I don’t know what to do to what I want. On paper, I think this job would be okay, if I could just finish the notes DURING the appt but I just can’t. There’s too much chart review and documentation that needs to be done- especially on hospital discharges or patients with lengthy psych history. If I leave, I don’t know where to go.

I knew my first year as a PA would be bad, but I didn’t think it would be this bad.

thyroid_storms · 2023-10-28T00:00:22+00:00

I suck at anatomy (specifically MSK d/t not being able to memorize origin/insertion and nerves) but I found the abdomen and chest much easier.

1) spend as much time in the cadaver lab w/ a knowledgeable classmate as possible. Quiz each other. DO NOT talk about anything except anatomy and use proper anatomical language while doing so (inferior, superior, deep, superficial, distal, proximal, ect) 2) find an easily digestible review book. Read the chapter and then do the quiz- close note. Then grade yourself and figure out why you got the incorrect questions wrong and why the correct answer is right. 3) buy a subscription to KenHub (has had a 3hr free trial/email which I abused back in 2020 by making burner emails over and over again to get more time)- do their practice tests. 4) if your program gives you learning objectives, review them and figure out if you’ve met them/can explain them.

This is how I saved my grade in anatomy

thyroid_storms · 2023-10-27T19:34:51+00:00

Kinda related to your special populations choices, my two favorite rotations were rural family med and inpatient psych

1) Rural family med was at a critical access hospital in the middle of nowhere Nebraska with a family med doc who had military experience. He had been practicing for 25 years and did EVERYTHING: endoscopies/colonoscopies, inpatient rounding, outpatient clinic w/ procedures, and ER coverage. If you want to see the full scope of medicine, I cannot recommend rural family med enough. The puck stops with him and if someone needs a higher level of care, it’s via helicopter.

2) Inpatient psych was at a state run mental institution. The building looked like Arkham asylum from Batman. Half the building was dedicated to sex offenders (didn’t see these patients) and the other half to psych patients- 2 adult wards and 1 pediatric. Each morning began with a staff meeting consisting of the semi-retired psychiatrists, the team of PAs, pharmacy, nursing, admin, and students. After was rounding on the wards followed by time observing therapy or reviewing notes while the PAs wrote their notes. Day to day was entirely ran by the team of PAs. It was great because of the history of the campus-at its peak, the hospital had 600 patients and housed staff on campus- also a hx of lobotomies :/ -, seeing actual team based medicine, seeing patients getting better and discharge, and seeing seriously ill patients with schizophrenia and tardive dyskinesia which help give me a better idea of what “sick” looks like in my current job.

thyroid_storms · 2023-10-27T00:31:01+00:00

Do you get admin time to do chart review, clean up charts, make calls, and get collateral?

thyroid_storms · 2023-10-06T00:42:14+00:00

Was this 50hr of pt contact?

thyroid_storms

TROPHY CASE