First job, having some trouble

[PsychPAinPA]

I graduated in May 2017 and started working in psychiatry in August 2017. I work for a small physician group, and my primary responsibility is rounding on an inpatient psych unit. 

I've been feeling unsupported and uncomfortable with my supervising physician, and can't tell if I'm being unreasonable or overreacting. I will often round alone in the mornings, and he will round in the evenings if he has other obligations in the morning. I am comfortable with this, and feel capable. However, there is a clinical psychologist on staff who has developed a pattern of undermining me. If I make a decision she disagrees with, she will call my supervising physician and regardless of the situation he will give an order to undo what I have done and do whatever she suggests. 

Typical example of this happening:

I saw a patient in the morning who the previous evening had presented in the ED saying she was suicidal. The ED called my supervising physician, and he gave the order to admit. When I saw her in the morning she was tearful, labile, screaming at staff and demanding discharge. She insisted she wasn't suicidal. She was generally very unpleasant. The therapists and nurse wanted to get her out so she'd stop being awful to them, but I felt uncomfortable immediately discharging her. She had said less than 12 hours prior that she was suicidal, and clearly was not emotionally stable at present. I explained my reasoning to the staff, including the psychologist, and ordered some Ativan to try to calm her behavior. I called my supervising physician, explained the situation, and what I had done. I said I'd rather he also see the patient when he rounds in the evening, and did not feel she was safe for discharge. He agreed. Half an hour later, the clinical psychologist contacted him and said she thought the patient should be discharged immediately. He called me, and told me to immediately discharge and write the discharge summary. He is my supervising physician, so I felt I had to do this even though I felt very uncomfortable as I was the only one who saw the patient and did not feel confident of her safety. 

I spoke to him and tried to explain why I was uncomfortable, but all I got was a lecture about cooperating with the treatment team. I'm not sure he understood that I feel as though he is neutering me by constantly overturning my decisions (even when he initially agrees with them), or that I wish he would see difficult patients himself before blindly trusting anyone's judgement. 

This is my first job, and I'm not sure if dynamics like this are unusual. 

[sas5814]

Yes and the biggest problem in this scenario is your SP. If he/she blows in the wind like that based on who called last or made the most noise then that is a big problem. It needs to be worked out and your SP needs to put on his big boy panties and be the physician. If he wants to talk about team he needs a better understanding of what that means and undermining each other, with his tacit and explicit consent and participation, isn't it.

DISCLAIMER: I am not a psych guy. The physician admitting a patient and then discharging the patient having never seen the patient seems like a perfect liability case. Are you liable for unlawfully confining a patient that didn't need to be admitted or did you put the patient at risk by discharging a potentially suicidal patient without actually seeing them? By doing both things the liability was greater than having just done one or the other.

Mostly it seems like everyone just needs to stay in their lane. My wife is a psych nurse and gets tired of me telling her we can't discharge patients just because they are a PIA to the nursing staff. If that was a criteria for discharge most psych hospitals would be pretty empty. The psychologist needs to confine himself/herself to talk therapy and butt out of other matters not relative. IMHO giving this patient a chill pill and having them stay until properly evaluated by the physician was the best course of action.

[BayPAC]

I would avoid any confrontation. It won't help you! Work there five more months, learn as much as you can and find a different job.  There are many jobs for psych PAs out there. With a year of experience under your belt, you will probably find a job where people respect you and that pays more than you are making now. 

[PsychPAinPA]

It 8 months too early to leave this job? Would it be difficult to justify leaving to future employers?

[UGoLong]

It is never, never too early to look around. And you certainly have reason to do so.

Just don’t be blaming the SP in your interviews. Most people don’t want who they feel will be a problem child.


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[DizzyJ]

Tough situation. As stated, your SP should be coming in and examining  the patient admitted under their name and you feel is unstable. You’re in a bad spot and I’d make sure your d/c summary states your concerns about discharging too early and risks of suicide. State that your SP and psychologist want her discharged and you’re just following orders basically. 

[ventana]

Going to provide a different viewpoint. 

 

You are a brand brand new grad. 

The PhD is established and trusted.

 Honestly you have no idea what you are doing

instead of thinking you are something special and your opinion should be respected(which as a new grad is debatable) how about befriending the psychologist and getting some training/mentoring from them.  

 

I work in a setting where I order 90% of the psych meds but only rarely see patients for a straight psych visit.  (I manage all medical as well).  I strongly depend on these clinicians for their assessments and rarely override them.  

 

Medicine is a team sport and and right now you are barely on the team and are brand new.  A touch of patience, humility and getting to know where you fit is in order.  

 

 

Final thought.  When you doc tells you to do something, do it and politically correctly document it was their decision.  I.e. case d/w Dr SoAndSo.  He decided it appropriate to d/c patient at this time.  Will d/c patient on order of Dr SoAndSo.   Never state you disagree, just that you are taking his order for d/c.  It is their call and in some places PA/NP are expressly forbidden on making admit or d/c decision (so it is beyond you scope)

[PsychPAinPA]

1 hour ago, ventana said:

Going to provide a different viewpoint. 

 

You are a brand brand new grad. 

The PhD is established and trusted.

 Honestly you have no idea what you are doing

instead of thinking you are something special and your opinion should be respected(which as a new grad is debatable) how about befriending the psychologist and getting some training/mentoring from them.  

 

I work in a setting where I order 90% of the psych meds but only rarely see patients for a straight psych visit.  (I manage all medical as well).  I strongly depend on these clinicians for their assessments and rarely override them.  

 

Medicine is a team sport and and right now you are barely on the team and are brand new.  A touch of patience, humility and getting to know where you fit is in order.  

 

 

Final thought.  When you doc tells you to do something, do it and politically correctly document it was their decision.  I.e. case d/w Dr SoAndSo.  He decided it appropriate to d/c patient at this time.  Will d/c patient on order of Dr SoAndSo.   Never state you disagree, just that you are taking his order for d/c.  It is their call and in some places PA/NP are expressly forbidden on making admit or d/c decision (so it is beyond you scope)

I've thought about this, and agree she definitely has more experience and I can see why her recommendation would carry more weight. I'm not trying to be arrogant, but this dynamic is making it hard for me to do the job they are asking me to do. I am responsible for rounding in the morning and managing any problems that arise until he arrives to round in the evening. This has been a pattern that if any of the staff at all disagree with anything I do, they call my SP and he overturns my decision regardless of the circumstances, regardless of the experience or training of the person calling, and regardless of whether or not he has seen the patient. I always politely and correctly carry out any orders he gives, but this has been bothering me increasingly as they have been giving me more autonomy and responsibility, but not allowing me to lead. 

[sas5814]

Then it is probably time to go. I'm not sure what his expectation was when he put you in this position but if anyone and everyone can just call him and get an over ride then you are probably superfluous. Either he doesn't need a new grad (no offense) or he can just let the staff manage his patients until he gets there in the evening.

Whatever the reasons it doesn't sound like a healthy fruitful dynamic.

[GetMeOuttaThisMess]

Again, let me go back to the stone age here. I would not doubt at all that you are in this position in his mind to perform three primary functions: 1) H&P, 2) daily rounds notation, and 3) D/C summary. I have no doubt at all that this was my primary role in my first two positions. In neither did I have my own patient profile (not unusual then).

 

[sas5814]

to expand on what Mess said maybe it's time to DTR (define the relationship). If his expectation is that you are a place holder until he gets there and you are comfortable with that.... problem solved. Your role will likely expand as you gain experience. If that is his expectation and you aren't happy with it either renegotiate or move on.

One of my many tropes I live by is either get happy with what you have or change your circumstances.

[GetMeOuttaThisMess]

1 hour ago, sas5814 said:

to expand on what Mess said maybe it's time to DTR (define the relationship). If his expectation is that you are a place holder until he gets there and you are comfortable with that.... problem solved. Your role will likely expand as you gain experience. If that is his expectation and you aren't happy with it either renegotiate or move on.

One of my many tropes I live by is either get happy with what you have or change your circumstances.

I could not agree more.  An occasional gripe is ok from any of us because we all know dealing with the public is a PITA.  If one is a constant complainer then you have two choices;  suck it up or move on.  This is the only real control any of us have.

Oh, and if this isn't enough, I have NEVER had a job where the job description that I was hired under didn't ultimately change, and it was NEVER for my benefit.  Thus, I've taken my own advice and moved on over the years.  So for those of you who are new and feel fortunate that you like your job at present time, just wait.

[SedRate]

1 hour ago, GetMeOuttaThisMess said:

So for those of you who are new and feel fortunate that you like your job at present time, just wait.

That's why I try to keep in touch with what's going on in the job market and who's hiring... You just never know what's going to happen.