Author: Daniel Carlat M.D.
Last Updated: 4/1/20
It’s 9 AM, and as you arrive at the nurse’s station to begin your day, the charge nurse greets you. “Good Morning Dr. Rogers, the two patients being discharged need their scripts and some forms signed.” “Will do, thanks” you respond. You pick up a census sheet and see that a new patients was admitted overnight, and, curious, you grab a chart and begin to read through it. Twenty minutes later, you hear the charge nurse. “Dr. Rogers, the cab is on it’s way for the first discharge. I didn’t see those scripts.” “Sorry, I’ll get right on that,” and you reach for the discharge sheet. As you begin to write out the 12 prescriptions, you’re interrupted by the social worker. “Dr. Rogers, are you ready for team?” You look at your watch. It’s 9:30 AM, and your team is already in the break room waiting for you. You sigh…the beginning of another long day.
Inpatient psychiatry can be many things—fast-paced, stressful, challenging, exhausting—but it’s rarely boring. You will always be pulled in multiple different directions, and the work environment usually challenges your ability to stay on track. A nurse’s station, where you’ll be doing most of your work, is cramped, filled with too many providers vying for charts or computers, and loud. The phone will be ringing, staff will be chatting, patients will be approaching with requests…and you will be trying to get some work done.
In this introductory chapter I’ll suggest a couple of roadmaps for how you can plan your day. Don’t let your day unravel like Dr. Rogers’ did in the example above. Come up with a plan of attack, and develop a system for yourself that helps insure you will be able to get your work done efficiently. A good system will help you to start your day with energy and optimism and maintain that attitude until your work is done.
A Recommended Schedule
This schedule assumes a 6 hour day, and doesn’t include any unanticipated non-clinical activities, such as hospital meetings (medical staff meetings, committee meetings etc….). In my experience, 6 hours will allow you to do a good job as an inpatient psychiatrist working with about 10 patients at a time. Some days will be shorter, others longer, depending on the census and how complicated your patients’ issues are. There are four broad categories of work for you to schedule into your days. 1. Pre-interview planning. 2. Patient Interview. 3. Team meeting. 4. Documentation.
8:00 AM-8:15. Pre-interview planning
8 AM is painfully early to have to show up at work, but early is better when it comes to inpatient work. You are no longer master of your own domain. You work with a staff of dozens of people who need to coordinate their schedules around yours, and vice versa. Getting an early start will allow everybody to get their work done more efficiently, and will allow you to leave the hospital at a reasonable time.
1. When you arrive, ask the charge nurse (the nurse manager) if there are any issues that require your immediate attention. Such issues might include ordering medications for a patient who is becoming agitated, clarifying an order the on call doctor made, or looking at some vital signs that are concerning.
2. Get your census sheet (the list of your patients) and determine your day’s work load. In the appendix you can find a “Daily Patient List” which I use, which has room for ten names, checkboxes for each patient and a little room for notes.
For each patient on your census sheet, I create two checkboxes:
☐Interview
☐Document
Depending on the patient, you may find other things that need doing, such as looking up a lab, calling a collateral, writing an order etc…. As you go through your day, try to make a habit of adding a checkbox each time a new task comes up. Don’t assume you’ll remember these things. That will clutter up your brain, which will in turn increase your stress level as you realize that you are juggling multiple tasks.
In my experience, here are the most common checkboxes that often get added to my patient lists
☐Check labs
☐Increase [med]
☐Call ______________
8:15-8:30. Take care of time sensitive issues.
These will usually be discharges. Write discharge orders and write out prescriptions or type them out if using EMR. (If you are super-organized you already wrote the scripts before you left the unit yesterday). Do a quick discharge interview with your patients (see the chapter on interviewing patients for tips on keeping these short and sweet).
8:30-10. Patient Interviews.
See your patients. Start with the high priority patients. I usually prioritize patients in the following order, from highest to lowest:
–Continuing patients with active behavioral issues, such as those who have been agitated, are at risk for restraints, are having significant side effects, etc….
–New patients. They may have been waiting since yesterday to see you, and nursing will be happy once you’ve answered questions that they have been forced to try to field in the interim.
–Continuing patients with managed care policies. Be sure to see these patients before team meeting, because your UR (utilization review) person will need information from you to justify authorization for more days.
–Continuing patients on Medicare (or other non-managed care policies).
10-11. Team meeting.
Units vary on their schedules and policies, but there will always be team meetings, and you will always be expected to be the “leader” of these meetings. On small units the team might consist of three people: the nurse, the social worker, and yourself. On larger units, there will also be an occupational therapist, a utilization review specialist, and a discharge planner.
The agenda is usually driven by the census list, and the charge nurse will start reading down the list, giving everybody a report on the patient’s behaviors, ADLS etc…
“Mr. Smith continues to self-dialog, he slept 4 hours, otherwise he mostly stayed in his room, and went to only one group.”
Then you might go around the room, with different staff chiming in about their impressions and updating the team on what they’ve done in terms of information-gathering and discharge planning. Occasionally you’ll have the patient come into the room in order to meet the team members and to ask questions to clarify what they believe needs to happen before discharge. Some hospitals require patient participation by policy, while others leave it up to the doctor. If you choose the “ultra-rapid psychiatry” technique (see below), you will see all your patients in team, because that’s the only time you budget to do your work.
How long should treatment teams take? That varies according to the number and complexity of the patients and the preferences of staff. Typically these meetings last from 30-60 minutes for a census of 10 patients. Try not to go longer than an hour—there’s a lot of other work to do on the unit and not much time to do it.
11-12. More Patient Interviews
See any patients you didn’t have time to see before team.
12-12:10 Lunch
Wolf down the sandwich you packed. Or grab something from the cafeteria. Go out for a proper lunch at your peril…the more you extend your day at the hospital, the more tasks the hospital will find for you to do.
12:10-2. Documentation
Time to write all your progress notes and dictate admission notes and discharge summaries. If you have extra time after that, consider spending more time with patients to get to know them better, calling informants, and looking up clinical topics to learn more about how to treat your patients. Then go home.
“Fast Psychiatry” variation: Combine interviewing and documenting.
It’s possible to take care of your inpatient work in 3 or 4 hours…or even less. To do this, you have to multi-task and spend less time talking to patients.
This means writing your notes while you are seeing patients. This works best if your hospital still uses paper charts, because then you can simply keep blank progress note sheets on your clipboard and write your notes wherever you happen to be when you do your interviews. Of course, you can also bring the entire chart into the interview room, but that can be difficult for other staff who may need to see the chart while you have it. You will have staff hunting you down to find the chart and they’ll start giving you dirty looks if that continues (however, see “ultra-fast psychiatry” below for a solution to this).
Some EHRs (electronic health records) allow you to use your e-tablet to document, and theoretically you could also lug your laptop around while seeing patients if your EHR requires input with a regular keyboard.
Advantages of combining seeing patients with charting include time efficiency and more accurate note taking since you are relying less on your memory of patient encounters. A disadvantage is that you may not connect with your patients as well since you’ll be dividing your attention between listening to them and documenting.
“Ultra Fast Psychiatry”: Combine interviewing, documentation, and team meeting.
Doing all your work in the context of team meeting can be a huge time-saver. In this scenario, you bring all your patients, one by one, into team, interview them in front of everybody there, discuss the treatment plan with staff, make all that day’s clinical decisions on the spot, write your notes and all your orders. This means that when team meeting is over, your day is almost done—I say “almost” because you’ll still have to spend some time documenting new admissions and discharges, which often entails dictating records.
The advantages of ultra-rapid psychiatry are the following:
–You can reliably plan to leave the hospital before noon, allowing you to have a second job in the afternoon, such as a private practice.
–You can see a lot of patients, which is a benefit to your colleagues when they are on vacation and somebody needs to cover for them.
–Some staff prefer this technique and find that it saves them time because major decisions are made quickly and fairly early in the day. Seeing all patients in team forces otherwise slow-moving doctors to make decisions more quickly, which moves everybody’s day along more quickly.
–Paradoxically, this method can enhance the quality of care because it forces you and staff to make all decisions collaboratively, usually in the presence of the patient. As the final decision-maker, this provides you with real-time information about how the patient has been doing, which can make your decisions better. Plus, patients feel like they are involved in their care decisions, because they see you and staff discussing their case and they can see how you arrived at decisions.
The disadvantages include:
–Some patients may not feel comfortable being interviewed in a team setting.
–Other patients may be too psychiatrically disabled to participate, such as those who are too agitated or paranoid to come into a small crowded room for the interview.
–You will not get to know your patients very well, depriving you of the rich clinical material that may have attracted you to psychiatry in the first place.
–Some unit staff may not be thrilled with this technique, because it means they are rearranging their schedule for your convenience. These meetings will typically take one to two hours out of everyone’s day—depriving staff of time which they would otherwise use to write their own notes, spend time with patients, make phone calls, etc…. Also, some staff may find the process tedious, because from their perspective they are being forced to watch you to your work.
Doing work in the afternoon
While I don’t recommend it, some doctors arrive at the unit later in the day, for a variety of more or less legitimate reasons. This ends up being inconvenient for everybody else, because major decisions have to remain on hold while patients are waiting for you. If this is unavoidable, try to compensate by getting some time sensitive work done the day before, and by calling into the unit in the morning to do a quick check in with the charge nurse and social worker.
Conclusion
There are lots of ways to do inpatient work, and chances are you will try out various schedules and permutations until you find something that works best with your personality, interests, and abilities.