Kaustubh G. Joshi, MD

Our 24-hour society has made night shift work essential to people in many professions, including medical specialties. Working nights disrupts homeostatic and circadian rhythms, which leads to an accumulation of sleep debt (ie, the cumulative effect of not getting enough sleep).¹ This debt can affect performance by impairing processing speed, concentration, mood, and physical health.¹ Night shift work takes place during the period of the sleep-wake cycle that is programmed for sleep; after the shift, workers need to sleep during the period that is least conducive to sleep.¹ Research indicates that a night shift worker’s sleep can be improved by scheduling light exposure and optimizing the timing of when they start their shifts.² However, this may not be practical because night shifts usually are scheduled at particular intervals and cannot be tailored to the individual worker’s preference. Additionally, in the short term, full circadian adaptation to night shifts is impossible.¹

Because sleep and performance are complex phenomena that are difficult to control, there is no single solution to maximizing these factors when one works nights.¹ The most effective approach to combating the effects of night shift work is individualized and multimodal.¹ However, whether you are working a night shift or are caring for a patient who does, the following nonpharmacologic strategies can help improve sleep and performance until the body naturally adapts to working this type of schedule^1,3:

Minimize sleep debt before starting aseries of night shifts by not setting an alarm on the morning before the first night shift and by napping in the afternoon for approximately 45 minutes.

Take a nap during a work break (if work demands allow you to do so). However, nap for <30 minutes to avoid slow-wave sleep and subsequent grogginess when awakening.

Expose yourself to bright light immediately upon waking and for 15 minutes 2 or 3 times during a shift to promote alertness.

Drink caffeinated beverages before and during the shift to help improve concentration and reasoning (if there is no medical contraindication to consuming caffeine). However, avoid caffeine for at least 3 hours prior to going to sleep.

Add additional checks to critical tasks, such as ordering medications, during the shift, especially during the physiological nadir in the early hours of the morning.

Continue to: Create a cool, dark, quiet environment for sleep...

Create a cool, dark, quiet environment for sleep using a comfortable mattress and pillow, blackout blinds, ear plugs, and a noise machine. Also, avoid using your smartphone or tablet while trying to go to sleep. Minimize exposure to bright light on the drive home, and stick to a routine (eg, for meals and exercise).

Avoid working too many consecutive night shifts (if possible) because this can increase sleep deprivation. Also, limiting the number of night shifts and scheduling days off can speed recovery from sleep deprivation.

Our 24-hour society has made night shift work essential to people in many professions, including medical specialties. Working nights disrupts homeostatic and circadian rhythms, which leads to an accumulation of sleep debt (ie, the cumulative effect of not getting enough sleep).¹ This debt can affect performance by impairing processing speed, concentration, mood, and physical health.¹ Night shift work takes place during the period of the sleep-wake cycle that is programmed for sleep; after the shift, workers need to sleep during the period that is least conducive to sleep.¹ Research indicates that a night shift worker’s sleep can be improved by scheduling light exposure and optimizing the timing of when they start their shifts.² However, this may not be practical because night shifts usually are scheduled at particular intervals and cannot be tailored to the individual worker’s preference. Additionally, in the short term, full circadian adaptation to night shifts is impossible.¹

Because sleep and performance are complex phenomena that are difficult to control, there is no single solution to maximizing these factors when one works nights.¹ The most effective approach to combating the effects of night shift work is individualized and multimodal.¹ However, whether you are working a night shift or are caring for a patient who does, the following nonpharmacologic strategies can help improve sleep and performance until the body naturally adapts to working this type of schedule^1,3:

Minimize sleep debt before starting aseries of night shifts by not setting an alarm on the morning before the first night shift and by napping in the afternoon for approximately 45 minutes.

Take a nap during a work break (if work demands allow you to do so). However, nap for <30 minutes to avoid slow-wave sleep and subsequent grogginess when awakening.

Expose yourself to bright light immediately upon waking and for 15 minutes 2 or 3 times during a shift to promote alertness.

Drink caffeinated beverages before and during the shift to help improve concentration and reasoning (if there is no medical contraindication to consuming caffeine). However, avoid caffeine for at least 3 hours prior to going to sleep.

Add additional checks to critical tasks, such as ordering medications, during the shift, especially during the physiological nadir in the early hours of the morning.

Continue to: Create a cool, dark, quiet environment for sleep...

Create a cool, dark, quiet environment for sleep using a comfortable mattress and pillow, blackout blinds, ear plugs, and a noise machine. Also, avoid using your smartphone or tablet while trying to go to sleep. Minimize exposure to bright light on the drive home, and stick to a routine (eg, for meals and exercise).

Avoid working too many consecutive night shifts (if possible) because this can increase sleep deprivation. Also, limiting the number of night shifts and scheduling days off can speed recovery from sleep deprivation.

Our 24-hour society has made night shift work essential to people in many professions, including medical specialties. Working nights disrupts homeostatic and circadian rhythms, which leads to an accumulation of sleep debt (ie, the cumulative effect of not getting enough sleep).¹ This debt can affect performance by impairing processing speed, concentration, mood, and physical health.¹ Night shift work takes place during the period of the sleep-wake cycle that is programmed for sleep; after the shift, workers need to sleep during the period that is least conducive to sleep.¹ Research indicates that a night shift worker’s sleep can be improved by scheduling light exposure and optimizing the timing of when they start their shifts.² However, this may not be practical because night shifts usually are scheduled at particular intervals and cannot be tailored to the individual worker’s preference. Additionally, in the short term, full circadian adaptation to night shifts is impossible.¹

Because sleep and performance are complex phenomena that are difficult to control, there is no single solution to maximizing these factors when one works nights.¹ The most effective approach to combating the effects of night shift work is individualized and multimodal.¹ However, whether you are working a night shift or are caring for a patient who does, the following nonpharmacologic strategies can help improve sleep and performance until the body naturally adapts to working this type of schedule^1,3:

Minimize sleep debt before starting aseries of night shifts by not setting an alarm on the morning before the first night shift and by napping in the afternoon for approximately 45 minutes.

Take a nap during a work break (if work demands allow you to do so). However, nap for <30 minutes to avoid slow-wave sleep and subsequent grogginess when awakening.

Expose yourself to bright light immediately upon waking and for 15 minutes 2 or 3 times during a shift to promote alertness.

Drink caffeinated beverages before and during the shift to help improve concentration and reasoning (if there is no medical contraindication to consuming caffeine). However, avoid caffeine for at least 3 hours prior to going to sleep.

Add additional checks to critical tasks, such as ordering medications, during the shift, especially during the physiological nadir in the early hours of the morning.

Continue to: Create a cool, dark, quiet environment for sleep...

Create a cool, dark, quiet environment for sleep using a comfortable mattress and pillow, blackout blinds, ear plugs, and a noise machine. Also, avoid using your smartphone or tablet while trying to go to sleep. Minimize exposure to bright light on the drive home, and stick to a routine (eg, for meals and exercise).

Avoid working too many consecutive night shifts (if possible) because this can increase sleep deprivation. Also, limiting the number of night shifts and scheduling days off can speed recovery from sleep deprivation.

Searching for someone on the Internet and viewing his or her social media profile is an effective way to obtain information about people, including patients. Following our patients’ “digital footprint” may help us understand the context of their lives, reconcile discrepancies in what they have told us, or allow us to confront denial and address incomplete reporting.¹ However, perusing our patients’ online profiles could negatively impact treatment and adherence. Consider these factors before looking up your patients’ online profiles^1-3:

Inaccurate information. Information on the Internet, especially what you can find on user-generated forums, is largely unregulated; as a result, the veracity of that information cannot be guaranteed.¹ Patients may choose to portray themselves inaccurately on their online profiles, and their identities often cannot be confirmed. Even if some information is accurate, you might discover things that you did not expect to learn about your patients, including important information that they did not share, or even something they lied about. This can create the conundrums of what to do with such information and how to discuss it at the next visit.

Impact on treatment. Despite patients’ online activities being displayed for the world to see, many patients do not expect their clinicians to access their online information. They might perceive such perusal as a breach of trust, which might lead some to view the doctor–patient relationship as adversarial. Accessing this information also could create a more intimate relationship than intended. Even if a clinician acquires consent to perform a search, patients may still feel coerced into allowing it because they might feel that declining to grant permission would make the clinician suspect that they have something to hide, or that the clinician would search without consent.²

In addition, if patients are aware that their psychiatrists are monitoring them, they might change their behavior. For example, they may delete certain data, add additional information that may not be accurate, or censor future social media posts. Knowing that their clinicians could be paying attention to them around the clock also might motivate certain patients to act out more or become withdrawn.

Possible medicolegal repercussions. If clinicians are able to access their patients’ electronic profiles, are they then legally obligated to monitor them? For example, if a patient who posts a picture with a noose around his neck later completes suicide, does the clinician who intermittently monitored this patient’s online profile face legal ramifications for not seeing the post? Do clinicians have to call 911 for vaguely suicidal tweets? What responsibilities does a clinician have at the first sign of an innocuous “sad” emoji? The sheer volume of online content that patients can create over different outlets is staggering. It can be overwhelming and ineffective to attempt to monitor patients’ online activities in addition to attending to one’s usual clinical duties, and the medicolegal repercussions of doing so are largely unknown.

Before searching the Internet to learn more about your patients, first consider the ramifications of doing so. While such searches could be helpful, they may lead to poor adherence, a lack of trust, or legal quagmires.

Searching for someone on the Internet and viewing his or her social media profile is an effective way to obtain information about people, including patients. Following our patients’ “digital footprint” may help us understand the context of their lives, reconcile discrepancies in what they have told us, or allow us to confront denial and address incomplete reporting.¹ However, perusing our patients’ online profiles could negatively impact treatment and adherence. Consider these factors before looking up your patients’ online profiles^1-3:

Inaccurate information. Information on the Internet, especially what you can find on user-generated forums, is largely unregulated; as a result, the veracity of that information cannot be guaranteed.¹ Patients may choose to portray themselves inaccurately on their online profiles, and their identities often cannot be confirmed. Even if some information is accurate, you might discover things that you did not expect to learn about your patients, including important information that they did not share, or even something they lied about. This can create the conundrums of what to do with such information and how to discuss it at the next visit.

Impact on treatment. Despite patients’ online activities being displayed for the world to see, many patients do not expect their clinicians to access their online information. They might perceive such perusal as a breach of trust, which might lead some to view the doctor–patient relationship as adversarial. Accessing this information also could create a more intimate relationship than intended. Even if a clinician acquires consent to perform a search, patients may still feel coerced into allowing it because they might feel that declining to grant permission would make the clinician suspect that they have something to hide, or that the clinician would search without consent.²

In addition, if patients are aware that their psychiatrists are monitoring them, they might change their behavior. For example, they may delete certain data, add additional information that may not be accurate, or censor future social media posts. Knowing that their clinicians could be paying attention to them around the clock also might motivate certain patients to act out more or become withdrawn.

Possible medicolegal repercussions. If clinicians are able to access their patients’ electronic profiles, are they then legally obligated to monitor them? For example, if a patient who posts a picture with a noose around his neck later completes suicide, does the clinician who intermittently monitored this patient’s online profile face legal ramifications for not seeing the post? Do clinicians have to call 911 for vaguely suicidal tweets? What responsibilities does a clinician have at the first sign of an innocuous “sad” emoji? The sheer volume of online content that patients can create over different outlets is staggering. It can be overwhelming and ineffective to attempt to monitor patients’ online activities in addition to attending to one’s usual clinical duties, and the medicolegal repercussions of doing so are largely unknown.

Before searching the Internet to learn more about your patients, first consider the ramifications of doing so. While such searches could be helpful, they may lead to poor adherence, a lack of trust, or legal quagmires.

Searching for someone on the Internet and viewing his or her social media profile is an effective way to obtain information about people, including patients. Following our patients’ “digital footprint” may help us understand the context of their lives, reconcile discrepancies in what they have told us, or allow us to confront denial and address incomplete reporting.¹ However, perusing our patients’ online profiles could negatively impact treatment and adherence. Consider these factors before looking up your patients’ online profiles^1-3:

Inaccurate information. Information on the Internet, especially what you can find on user-generated forums, is largely unregulated; as a result, the veracity of that information cannot be guaranteed.¹ Patients may choose to portray themselves inaccurately on their online profiles, and their identities often cannot be confirmed. Even if some information is accurate, you might discover things that you did not expect to learn about your patients, including important information that they did not share, or even something they lied about. This can create the conundrums of what to do with such information and how to discuss it at the next visit.

Impact on treatment. Despite patients’ online activities being displayed for the world to see, many patients do not expect their clinicians to access their online information. They might perceive such perusal as a breach of trust, which might lead some to view the doctor–patient relationship as adversarial. Accessing this information also could create a more intimate relationship than intended. Even if a clinician acquires consent to perform a search, patients may still feel coerced into allowing it because they might feel that declining to grant permission would make the clinician suspect that they have something to hide, or that the clinician would search without consent.²

In addition, if patients are aware that their psychiatrists are monitoring them, they might change their behavior. For example, they may delete certain data, add additional information that may not be accurate, or censor future social media posts. Knowing that their clinicians could be paying attention to them around the clock also might motivate certain patients to act out more or become withdrawn.

Possible medicolegal repercussions. If clinicians are able to access their patients’ electronic profiles, are they then legally obligated to monitor them? For example, if a patient who posts a picture with a noose around his neck later completes suicide, does the clinician who intermittently monitored this patient’s online profile face legal ramifications for not seeing the post? Do clinicians have to call 911 for vaguely suicidal tweets? What responsibilities does a clinician have at the first sign of an innocuous “sad” emoji? The sheer volume of online content that patients can create over different outlets is staggering. It can be overwhelming and ineffective to attempt to monitor patients’ online activities in addition to attending to one’s usual clinical duties, and the medicolegal repercussions of doing so are largely unknown.

Before searching the Internet to learn more about your patients, first consider the ramifications of doing so. While such searches could be helpful, they may lead to poor adherence, a lack of trust, or legal quagmires.

Unless your practice is cash-only, reimbursements from your patients’ health insurance companies are necessary to ensure its survival. Although the reimbursement process appears straightforward (provide a service, submit a claim, and receive a payment), it is actually quite complex, and, if not properly managed, a claim can be denied at any stage of the process.¹ In its 2013 National Health Insurer Report Card, the American Medical Association reported that major payers returned 11% to 29% of claim lines with $0 for payment.^1,2 This often is the case because patients are responsible for the balance, but it also occurs as the result of claim edits (up to 7%) and other denials (up to 5%).^1,2

Claims can be denied for various reasons, including¹:

• missed filing deadlines
• billing for non-covered services
• discrepancies between diagnostic codes, procedures codes, modifiers, and clinician documentation
• missing pre-authorization documentation or a signed Advanced Beneficiary Notice of Non-Coverage.

Strategies for avoiding denials

A psychiatric practice requires a practical system to prevent the occurrence of denials, starting from the point of referral. Working through denials is more costly and time­consuming than preventing them from occurring in the first place. For every 15 denials prevented each month, your practice can save approximately $4,500 per year in costs associated with correcting those claims; by preventing denials, the practice also receives reimbursement sooner.¹ You can be guaranteed to leave significant amounts of money on the table if you are not able to prevent or reduce denials.

The following methods can be used to help reduce the likelihood of having a claim denied.^1,3

Obtain the patient’s health insurance information at first contact and confirm his or her coverage benefits, deductibles, copay requirements, and exclusions before scheduling the first appointment. Verify this information at each of the patient’s subsequent visits to reduce the chances of having a claim denied due to invalid subscriber information. Also, keep in mind that Medicaid eligibility can change daily.

Employ a digital record system, such as electronic medical records, to track authorizations.

Know the filing deadlines for each of your payers. If you miss a deadline, there is no recourse.

Continue to: Check each claim

Check each claim for accurate coding, diagnosis, and payment (eg, copay, co-insurance, and/or deductible, depending on the health insurance plan) taken before the claim is submitted. If your practice size permits, assign a staff member to confirm this information and keep track of deadlines for submissions, resubmissions, and appeals of denied claims. Using a single gatekeeper can help decrease the chances that a denial will “slip through the cracks.”

Confirm that diagnostic codes, procedures codes, and modifiers are justified by the clinician’s documentation. Have a medical coder compare notes with the clinician to determine if any critical information needed to justify the codes used has been omitted.

Implement an electronic system that can automatically identify any changes and updates to the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, International Classification of Diseases (ICD) versions and codes, and Current Procedural Terminology (CPT) codes and guidelines. To help reduce denied claims, educate all staff (schedulers, coders, billers, nursing staff, and other clinicians) frequently about these changes, and provide regular feedback to those involved in correcting denials.

Unless your practice is cash-only, reimbursements from your patients’ health insurance companies are necessary to ensure its survival. Although the reimbursement process appears straightforward (provide a service, submit a claim, and receive a payment), it is actually quite complex, and, if not properly managed, a claim can be denied at any stage of the process.¹ In its 2013 National Health Insurer Report Card, the American Medical Association reported that major payers returned 11% to 29% of claim lines with $0 for payment.^1,2 This often is the case because patients are responsible for the balance, but it also occurs as the result of claim edits (up to 7%) and other denials (up to 5%).^1,2

Claims can be denied for various reasons, including¹:

• missed filing deadlines
• billing for non-covered services
• discrepancies between diagnostic codes, procedures codes, modifiers, and clinician documentation
• missing pre-authorization documentation or a signed Advanced Beneficiary Notice of Non-Coverage.

Strategies for avoiding denials

A psychiatric practice requires a practical system to prevent the occurrence of denials, starting from the point of referral. Working through denials is more costly and time­consuming than preventing them from occurring in the first place. For every 15 denials prevented each month, your practice can save approximately $4,500 per year in costs associated with correcting those claims; by preventing denials, the practice also receives reimbursement sooner.¹ You can be guaranteed to leave significant amounts of money on the table if you are not able to prevent or reduce denials.

The following methods can be used to help reduce the likelihood of having a claim denied.^1,3

Obtain the patient’s health insurance information at first contact and confirm his or her coverage benefits, deductibles, copay requirements, and exclusions before scheduling the first appointment. Verify this information at each of the patient’s subsequent visits to reduce the chances of having a claim denied due to invalid subscriber information. Also, keep in mind that Medicaid eligibility can change daily.

Employ a digital record system, such as electronic medical records, to track authorizations.

Know the filing deadlines for each of your payers. If you miss a deadline, there is no recourse.

Continue to: Check each claim

Check each claim for accurate coding, diagnosis, and payment (eg, copay, co-insurance, and/or deductible, depending on the health insurance plan) taken before the claim is submitted. If your practice size permits, assign a staff member to confirm this information and keep track of deadlines for submissions, resubmissions, and appeals of denied claims. Using a single gatekeeper can help decrease the chances that a denial will “slip through the cracks.”

Confirm that diagnostic codes, procedures codes, and modifiers are justified by the clinician’s documentation. Have a medical coder compare notes with the clinician to determine if any critical information needed to justify the codes used has been omitted.

Implement an electronic system that can automatically identify any changes and updates to the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, International Classification of Diseases (ICD) versions and codes, and Current Procedural Terminology (CPT) codes and guidelines. To help reduce denied claims, educate all staff (schedulers, coders, billers, nursing staff, and other clinicians) frequently about these changes, and provide regular feedback to those involved in correcting denials.

Unless your practice is cash-only, reimbursements from your patients’ health insurance companies are necessary to ensure its survival. Although the reimbursement process appears straightforward (provide a service, submit a claim, and receive a payment), it is actually quite complex, and, if not properly managed, a claim can be denied at any stage of the process.¹ In its 2013 National Health Insurer Report Card, the American Medical Association reported that major payers returned 11% to 29% of claim lines with $0 for payment.^1,2 This often is the case because patients are responsible for the balance, but it also occurs as the result of claim edits (up to 7%) and other denials (up to 5%).^1,2

Claims can be denied for various reasons, including¹:

• missed filing deadlines
• billing for non-covered services
• discrepancies between diagnostic codes, procedures codes, modifiers, and clinician documentation
• missing pre-authorization documentation or a signed Advanced Beneficiary Notice of Non-Coverage.

Strategies for avoiding denials

A psychiatric practice requires a practical system to prevent the occurrence of denials, starting from the point of referral. Working through denials is more costly and time­consuming than preventing them from occurring in the first place. For every 15 denials prevented each month, your practice can save approximately $4,500 per year in costs associated with correcting those claims; by preventing denials, the practice also receives reimbursement sooner.¹ You can be guaranteed to leave significant amounts of money on the table if you are not able to prevent or reduce denials.

The following methods can be used to help reduce the likelihood of having a claim denied.^1,3

Obtain the patient’s health insurance information at first contact and confirm his or her coverage benefits, deductibles, copay requirements, and exclusions before scheduling the first appointment. Verify this information at each of the patient’s subsequent visits to reduce the chances of having a claim denied due to invalid subscriber information. Also, keep in mind that Medicaid eligibility can change daily.

Employ a digital record system, such as electronic medical records, to track authorizations.

Know the filing deadlines for each of your payers. If you miss a deadline, there is no recourse.

Continue to: Check each claim

Check each claim for accurate coding, diagnosis, and payment (eg, copay, co-insurance, and/or deductible, depending on the health insurance plan) taken before the claim is submitted. If your practice size permits, assign a staff member to confirm this information and keep track of deadlines for submissions, resubmissions, and appeals of denied claims. Using a single gatekeeper can help decrease the chances that a denial will “slip through the cracks.”

Confirm that diagnostic codes, procedures codes, and modifiers are justified by the clinician’s documentation. Have a medical coder compare notes with the clinician to determine if any critical information needed to justify the codes used has been omitted.

Implement an electronic system that can automatically identify any changes and updates to the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, International Classification of Diseases (ICD) versions and codes, and Current Procedural Terminology (CPT) codes and guidelines. To help reduce denied claims, educate all staff (schedulers, coders, billers, nursing staff, and other clinicians) frequently about these changes, and provide regular feedback to those involved in correcting denials.

Working at a long-term psychiatric hospital can present challenges similar to those found in other institutions, such as correctional facilities¹; however, in this setting, additional obstacles that could affect treatment may not readily come to mind. Following the 2 simple approaches described here can help you to understand your patient’s point of view and improve the treatment relationship.

Allow patients some control. Many patients in long-term psychiatric hospitals are prescribed medications that can result in metabolic complications such as weight gain or hyperlipidemia. To avoid these complications, we may need to institute dietary restrictions. Despite our explanations of why these restrictions are necessary, some patients may continue to insist on eating food that we believe will worsen their physical health; they may feel that they have little control in their lives and have nothing to look forward to except for what they can eat.²

For patients in long-term psychiatric hospitals, everyday life usually is structured from morning to evening. This includes when meals and snacks are served, as well as what they are allowed to eat. Food is a basic human necessity, and we often forget its psychological significance. Because most patients can control what they put in their mouths, food allows them to exert control in an environment where they may believe they have no influence. This may explain why patients insist on certain meals, purchase unhealthy food, or engage in a surreptitious snack distribution system with other patients. We usually can decide what and when we eat, but many of our hospitalized patients do not have that opportunity. Within reason, negotiating meals and snacks could provide patients with a sense of control, and might increase treatment compliance.²

Mind what you say. At the hospital, patients are acutely aware that we are there for a short period each day. For these patients, the hospital serves as their home. Many will live there for months to years; some will spend the remainder of their lives there. The way these patients view us can become adversely affected when they see that we occasionally bring a negative attitude toward having to spend the day in their living space, telling them how to behave and what to do. This daily temporary relationship between hospital staff and patients can greatly affect treatment.

Although the hospital can serve as a home, patients do not have input into how we should behave in their home. Be mindful of your actions and the comments you make while in the hospital. We would not appreciate someone making a negative comment about our homes, so it is likely that our patients do not want to hear us complain about the hospital. Furthermore, they likely do not enjoy hearing hospital staff discussing plans they have made in their personal lives. Many patients do not enjoy being in the hospital, and they could view such expressions as “rubbing it in,” which could adversely affect treatment.

Working at a long-term psychiatric hospital can present challenges similar to those found in other institutions, such as correctional facilities¹; however, in this setting, additional obstacles that could affect treatment may not readily come to mind. Following the 2 simple approaches described here can help you to understand your patient’s point of view and improve the treatment relationship.

Allow patients some control. Many patients in long-term psychiatric hospitals are prescribed medications that can result in metabolic complications such as weight gain or hyperlipidemia. To avoid these complications, we may need to institute dietary restrictions. Despite our explanations of why these restrictions are necessary, some patients may continue to insist on eating food that we believe will worsen their physical health; they may feel that they have little control in their lives and have nothing to look forward to except for what they can eat.²

For patients in long-term psychiatric hospitals, everyday life usually is structured from morning to evening. This includes when meals and snacks are served, as well as what they are allowed to eat. Food is a basic human necessity, and we often forget its psychological significance. Because most patients can control what they put in their mouths, food allows them to exert control in an environment where they may believe they have no influence. This may explain why patients insist on certain meals, purchase unhealthy food, or engage in a surreptitious snack distribution system with other patients. We usually can decide what and when we eat, but many of our hospitalized patients do not have that opportunity. Within reason, negotiating meals and snacks could provide patients with a sense of control, and might increase treatment compliance.²

Mind what you say. At the hospital, patients are acutely aware that we are there for a short period each day. For these patients, the hospital serves as their home. Many will live there for months to years; some will spend the remainder of their lives there. The way these patients view us can become adversely affected when they see that we occasionally bring a negative attitude toward having to spend the day in their living space, telling them how to behave and what to do. This daily temporary relationship between hospital staff and patients can greatly affect treatment.

Although the hospital can serve as a home, patients do not have input into how we should behave in their home. Be mindful of your actions and the comments you make while in the hospital. We would not appreciate someone making a negative comment about our homes, so it is likely that our patients do not want to hear us complain about the hospital. Furthermore, they likely do not enjoy hearing hospital staff discussing plans they have made in their personal lives. Many patients do not enjoy being in the hospital, and they could view such expressions as “rubbing it in,” which could adversely affect treatment.

Working at a long-term psychiatric hospital can present challenges similar to those found in other institutions, such as correctional facilities¹; however, in this setting, additional obstacles that could affect treatment may not readily come to mind. Following the 2 simple approaches described here can help you to understand your patient’s point of view and improve the treatment relationship.

Allow patients some control. Many patients in long-term psychiatric hospitals are prescribed medications that can result in metabolic complications such as weight gain or hyperlipidemia. To avoid these complications, we may need to institute dietary restrictions. Despite our explanations of why these restrictions are necessary, some patients may continue to insist on eating food that we believe will worsen their physical health; they may feel that they have little control in their lives and have nothing to look forward to except for what they can eat.²

For patients in long-term psychiatric hospitals, everyday life usually is structured from morning to evening. This includes when meals and snacks are served, as well as what they are allowed to eat. Food is a basic human necessity, and we often forget its psychological significance. Because most patients can control what they put in their mouths, food allows them to exert control in an environment where they may believe they have no influence. This may explain why patients insist on certain meals, purchase unhealthy food, or engage in a surreptitious snack distribution system with other patients. We usually can decide what and when we eat, but many of our hospitalized patients do not have that opportunity. Within reason, negotiating meals and snacks could provide patients with a sense of control, and might increase treatment compliance.²

Mind what you say. At the hospital, patients are acutely aware that we are there for a short period each day. For these patients, the hospital serves as their home. Many will live there for months to years; some will spend the remainder of their lives there. The way these patients view us can become adversely affected when they see that we occasionally bring a negative attitude toward having to spend the day in their living space, telling them how to behave and what to do. This daily temporary relationship between hospital staff and patients can greatly affect treatment.

Although the hospital can serve as a home, patients do not have input into how we should behave in their home. Be mindful of your actions and the comments you make while in the hospital. We would not appreciate someone making a negative comment about our homes, so it is likely that our patients do not want to hear us complain about the hospital. Furthermore, they likely do not enjoy hearing hospital staff discussing plans they have made in their personal lives. Many patients do not enjoy being in the hospital, and they could view such expressions as “rubbing it in,” which could adversely affect treatment.

Patients with personality disorders can disrupt the treatment relationship, and may leave us feeling angry, ineffective, inadequate, and defeated. Although their behaviors may appear volitional and purposeful, they often are the result of a dysfunctional personality structure.¹ These patients’ unbending patterns of viewing themselves, interacting with others, and navigating the world can be problematic in an inpatient or outpatient setting, causing distress for both the staff and patient. Because no 2 personalities are identical, there is no algorithm for managing patients with personality disorders. However, there are strategies that we can apply to provide effective clinical care.^1,2

Discuss the responses the patient evokes. Patients with personality disorders can elicit strong responses from the treatment team. Each clinician can have a different response to the same patient, ranging from feeling the need to protect the patient to strongly disliking him or her. Because cohesion among staff is essential for effective patient care, we need to discuss these responses in an open forum with our team members so we can effectively manage our responses and provide the patient with consistent interactions. Limiting the delivery of inconsistent or conflicting messages will decrease staff splitting and increase team unity.

Reinforce appropriate behaviors. Patients with personality disorders usually have negative interpersonal interactions, such as acting out, misinterpreting neutral social cues, and seeking constant attention. However, when they are not engaging in detrimental behaviors, we should provide positive reinforcement for appropriate behaviors, such as remaining composed, that help maintain the treatment relationship. When a patient displays disruptive behaviors, take a neutral approach by stating, “You appear upset. I will come back later when you are feeling better.”¹

Set limits. These patients are likely to have difficulty conforming to appropriate social boundaries. Our reflex reaction may be to set concrete rules that fit our preferences. This could lead to a power struggle between us and our patients, which is not helpful. Rather than a “one-size-fits-all” approach to rules, it may be prudent to tailor boundaries according to each patient’s unique personality. Also, allowing the patient to help set these limits could increase the chances that he or she will follow your treatment plan and reinforce the more positive aspects of his or her person­ality structure.

Offer empathy. Empathy can be conceptualized as a step further than sympathy; in addition to expressing concern and compassion, empathy involves recognizing and sharing the patient’s emotions. Seek to comprehend the reasons behind a patient’s negative reactions by identifying and understanding his or her feelings. Empathy also can help us avoid further resistance by considering what is appropriate to say to patients.

Patients with personality disorders can disrupt the treatment relationship, and may leave us feeling angry, ineffective, inadequate, and defeated. Although their behaviors may appear volitional and purposeful, they often are the result of a dysfunctional personality structure.¹ These patients’ unbending patterns of viewing themselves, interacting with others, and navigating the world can be problematic in an inpatient or outpatient setting, causing distress for both the staff and patient. Because no 2 personalities are identical, there is no algorithm for managing patients with personality disorders. However, there are strategies that we can apply to provide effective clinical care.^1,2

Discuss the responses the patient evokes. Patients with personality disorders can elicit strong responses from the treatment team. Each clinician can have a different response to the same patient, ranging from feeling the need to protect the patient to strongly disliking him or her. Because cohesion among staff is essential for effective patient care, we need to discuss these responses in an open forum with our team members so we can effectively manage our responses and provide the patient with consistent interactions. Limiting the delivery of inconsistent or conflicting messages will decrease staff splitting and increase team unity.

Reinforce appropriate behaviors. Patients with personality disorders usually have negative interpersonal interactions, such as acting out, misinterpreting neutral social cues, and seeking constant attention. However, when they are not engaging in detrimental behaviors, we should provide positive reinforcement for appropriate behaviors, such as remaining composed, that help maintain the treatment relationship. When a patient displays disruptive behaviors, take a neutral approach by stating, “You appear upset. I will come back later when you are feeling better.”¹

Set limits. These patients are likely to have difficulty conforming to appropriate social boundaries. Our reflex reaction may be to set concrete rules that fit our preferences. This could lead to a power struggle between us and our patients, which is not helpful. Rather than a “one-size-fits-all” approach to rules, it may be prudent to tailor boundaries according to each patient’s unique personality. Also, allowing the patient to help set these limits could increase the chances that he or she will follow your treatment plan and reinforce the more positive aspects of his or her person­ality structure.

Offer empathy. Empathy can be conceptualized as a step further than sympathy; in addition to expressing concern and compassion, empathy involves recognizing and sharing the patient’s emotions. Seek to comprehend the reasons behind a patient’s negative reactions by identifying and understanding his or her feelings. Empathy also can help us avoid further resistance by considering what is appropriate to say to patients.

Patients with personality disorders can disrupt the treatment relationship, and may leave us feeling angry, ineffective, inadequate, and defeated. Although their behaviors may appear volitional and purposeful, they often are the result of a dysfunctional personality structure.¹ These patients’ unbending patterns of viewing themselves, interacting with others, and navigating the world can be problematic in an inpatient or outpatient setting, causing distress for both the staff and patient. Because no 2 personalities are identical, there is no algorithm for managing patients with personality disorders. However, there are strategies that we can apply to provide effective clinical care.^1,2

Discuss the responses the patient evokes. Patients with personality disorders can elicit strong responses from the treatment team. Each clinician can have a different response to the same patient, ranging from feeling the need to protect the patient to strongly disliking him or her. Because cohesion among staff is essential for effective patient care, we need to discuss these responses in an open forum with our team members so we can effectively manage our responses and provide the patient with consistent interactions. Limiting the delivery of inconsistent or conflicting messages will decrease staff splitting and increase team unity.

Reinforce appropriate behaviors. Patients with personality disorders usually have negative interpersonal interactions, such as acting out, misinterpreting neutral social cues, and seeking constant attention. However, when they are not engaging in detrimental behaviors, we should provide positive reinforcement for appropriate behaviors, such as remaining composed, that help maintain the treatment relationship. When a patient displays disruptive behaviors, take a neutral approach by stating, “You appear upset. I will come back later when you are feeling better.”¹

Set limits. These patients are likely to have difficulty conforming to appropriate social boundaries. Our reflex reaction may be to set concrete rules that fit our preferences. This could lead to a power struggle between us and our patients, which is not helpful. Rather than a “one-size-fits-all” approach to rules, it may be prudent to tailor boundaries according to each patient’s unique personality. Also, allowing the patient to help set these limits could increase the chances that he or she will follow your treatment plan and reinforce the more positive aspects of his or her person­ality structure.

Offer empathy. Empathy can be conceptualized as a step further than sympathy; in addition to expressing concern and compassion, empathy involves recognizing and sharing the patient’s emotions. Seek to comprehend the reasons behind a patient’s negative reactions by identifying and understanding his or her feelings. Empathy also can help us avoid further resistance by considering what is appropriate to say to patients.

The ubiquitous use of e-mail has opened the proverbial “Pandora’s box” of access to psychiatrists. Our e-mail addresses are readily available online via search engines or on hospital Web sites. E-mail has become a convenient method of communicating with patients; however, it also has resulted in a proliferation of unsolicited e-mails sent to physicians from people they don’t know seeking professional advice.¹ If you publish medical literature or make media appearances, you may be contacted by such individuals requesting your expertise.

Unsolicited e-mails present psychiatrists with ethical and legal quandaries that force them to consider how they can balance the human reflex to offer assistance against the potential ramifications of replying. These conundrums include:

• whether the sender is an actual person, and whether he or she is asking for advice
• the risks of replying vs not replying
• the possibility that there is a plausible crisis or danger to the sender or others
• the potential for establishing a doctor–patient relationship by replying
• the legal liability that might be incurred by replying.²

Take preemptive measures

There is guidance on how to e-mail your patients and respond to solicited e-mails, but there is a dearth of literature on how to respond to unsolicited e-mails. Anecdotal reports and limited literature suggest several possible measures you could take for managing unsolicited e-mails:

• Establish a policy of never opening unsolicited e-mails
• Create a strict junk-mail filter to prevent unsolicited e-mails from being delivered to your inbox
• Set up an automatic reply stating that unwanted or unsolicited e-mails will not be read and/or that no reply will be provided
• Read unsolicited e-mails, but immediately delete them without replying
• Acknowledge the sender in a reply, but state that you are unable to assist and decline further contact
• Send a generic reply clarifying that you are unable to provide medical assistance, and encourage the sender to seek help locally.²

Despite the urge to help, consider the consequences

In addition to taking up valuable time, unsolicited e-mails create legal and ethical predicaments that could subject you to legal liability if you choose to reply. Even though your intentions may be altruistic and you want to be helpful, you may unknowingly create problems for yourself. Clinicians should carefully weigh the consequences of replying before clicking “send.”

The ubiquitous use of e-mail has opened the proverbial “Pandora’s box” of access to psychiatrists. Our e-mail addresses are readily available online via search engines or on hospital Web sites. E-mail has become a convenient method of communicating with patients; however, it also has resulted in a proliferation of unsolicited e-mails sent to physicians from people they don’t know seeking professional advice.¹ If you publish medical literature or make media appearances, you may be contacted by such individuals requesting your expertise.

Unsolicited e-mails present psychiatrists with ethical and legal quandaries that force them to consider how they can balance the human reflex to offer assistance against the potential ramifications of replying. These conundrums include:

• whether the sender is an actual person, and whether he or she is asking for advice
• the risks of replying vs not replying
• the possibility that there is a plausible crisis or danger to the sender or others
• the potential for establishing a doctor–patient relationship by replying
• the legal liability that might be incurred by replying.²

Take preemptive measures

There is guidance on how to e-mail your patients and respond to solicited e-mails, but there is a dearth of literature on how to respond to unsolicited e-mails. Anecdotal reports and limited literature suggest several possible measures you could take for managing unsolicited e-mails:

• Establish a policy of never opening unsolicited e-mails
• Create a strict junk-mail filter to prevent unsolicited e-mails from being delivered to your inbox
• Set up an automatic reply stating that unwanted or unsolicited e-mails will not be read and/or that no reply will be provided
• Read unsolicited e-mails, but immediately delete them without replying
• Acknowledge the sender in a reply, but state that you are unable to assist and decline further contact
• Send a generic reply clarifying that you are unable to provide medical assistance, and encourage the sender to seek help locally.²

Despite the urge to help, consider the consequences

In addition to taking up valuable time, unsolicited e-mails create legal and ethical predicaments that could subject you to legal liability if you choose to reply. Even though your intentions may be altruistic and you want to be helpful, you may unknowingly create problems for yourself. Clinicians should carefully weigh the consequences of replying before clicking “send.”

The ubiquitous use of e-mail has opened the proverbial “Pandora’s box” of access to psychiatrists. Our e-mail addresses are readily available online via search engines or on hospital Web sites. E-mail has become a convenient method of communicating with patients; however, it also has resulted in a proliferation of unsolicited e-mails sent to physicians from people they don’t know seeking professional advice.¹ If you publish medical literature or make media appearances, you may be contacted by such individuals requesting your expertise.

Unsolicited e-mails present psychiatrists with ethical and legal quandaries that force them to consider how they can balance the human reflex to offer assistance against the potential ramifications of replying. These conundrums include:

• whether the sender is an actual person, and whether he or she is asking for advice
• the risks of replying vs not replying
• the possibility that there is a plausible crisis or danger to the sender or others
• the potential for establishing a doctor–patient relationship by replying
• the legal liability that might be incurred by replying.²

Take preemptive measures

There is guidance on how to e-mail your patients and respond to solicited e-mails, but there is a dearth of literature on how to respond to unsolicited e-mails. Anecdotal reports and limited literature suggest several possible measures you could take for managing unsolicited e-mails:

• Establish a policy of never opening unsolicited e-mails
• Create a strict junk-mail filter to prevent unsolicited e-mails from being delivered to your inbox
• Set up an automatic reply stating that unwanted or unsolicited e-mails will not be read and/or that no reply will be provided
• Read unsolicited e-mails, but immediately delete them without replying
• Acknowledge the sender in a reply, but state that you are unable to assist and decline further contact
• Send a generic reply clarifying that you are unable to provide medical assistance, and encourage the sender to seek help locally.²

Despite the urge to help, consider the consequences

In addition to taking up valuable time, unsolicited e-mails create legal and ethical predicaments that could subject you to legal liability if you choose to reply. Even though your intentions may be altruistic and you want to be helpful, you may unknowingly create problems for yourself. Clinicians should carefully weigh the consequences of replying before clicking “send.”

Attention-deficit/hyperactivity disorder (ADHD) affects 5% of children and adolescents worldwide.¹ Children with ADHD commonly have trouble with attention, hyperactivity, impulsivity, organization, and emotional reactivity, and these difficulties can result in behaviors that frustrate, worry, and overwhelm parents, teachers, and other caregivers.

Extensive evidence supports stimulants as a first-line treatment. However, nonpharmacologic interventions are important, yet often overlooked, adjuncts that can be helpful for children who have a partial response to stimulants or are not prescribed medication. Teaching caregivers to use the following interventions will allow them to help children better navigate situations that require managing their symptoms, such as in a classroom setting.²

Attention. Children with ADHD typically find it challenging to prioritize what to focus on, sustain that focus, and switch between tasks. Shouting instructions often is unproductive. Therefore, encourage parents and teachers to use clear and concise instructions with supplementary visual tools to aid these children. When providing instructions in classrooms, teachers should look directly at the student and call him (her) by name. It also can be helpful to have the student repeat the instructions. Seating students with ADHD near the front of the classroom, close to the teacher and away from other distracting students, can improve their focus and allow the teacher to more easily give nonverbal cues, such as tapping on the student’s desk if his attention is waning.

Hyperactivity. Children with ADHD are prone to excessive talkativeness and continuous motor movement; therefore, sitting still for long periods can be exceptionally difficult. Teachers and caregivers should keep assignments short. For students whose primary manifestation of ADHD is hyperactivity, sitting near the back of the classroom will allow them to stand and stretch without disrupting the class. Occasionally giving these students a time-limited, acceptable outlet for their urge to move may be beneficial.

Impulsivity. Children who exhibit this symptom are more focused on the present and have difficulty weighing the consequences of their actions. Allowing these children to take frequent breaks (eg, more play time) will let their brains rest and recharge so that they can take a step back to evaluate the outcomes of their actions. Instruct parents and teachers to give children with ADHD regular verbal or written feedback to monitor and modify behaviors over time. Consequences for not following the rules should be immediate and consistent.

Organization. School assignments require sequencing, planning, and time management. Therefore, having daily visual reminders of prioritized assignments and schedules is helpful for children with ADHD, both at school and at home. Teachers and parents can help children stay organized by checking and reviewing the child’s agenda with him several times a day; this will allow him more time to think about what he needs to do to complete assignments.Emotional reactivity. Children with ADHD become frustrated easily and often are particularly sensitive to disappointment because of the continuous redirection they receive. Normalizing their mistakes by reinforcing that everyone makes mistakes and teaching them to learn from their mistakes can help reduce their embarrassment.

It also can be helpful to identify triggers for emotional reactivity. Parents and teachers should minimize the amount of talking when a child is unable to control his emotions. Helping children label their emotions, developing strategies for when they become upset, and outlining clear consequences for unacceptable behaviors can help modify their reactions.

Attention-deficit/hyperactivity disorder (ADHD) affects 5% of children and adolescents worldwide.¹ Children with ADHD commonly have trouble with attention, hyperactivity, impulsivity, organization, and emotional reactivity, and these difficulties can result in behaviors that frustrate, worry, and overwhelm parents, teachers, and other caregivers.

Extensive evidence supports stimulants as a first-line treatment. However, nonpharmacologic interventions are important, yet often overlooked, adjuncts that can be helpful for children who have a partial response to stimulants or are not prescribed medication. Teaching caregivers to use the following interventions will allow them to help children better navigate situations that require managing their symptoms, such as in a classroom setting.²

Attention. Children with ADHD typically find it challenging to prioritize what to focus on, sustain that focus, and switch between tasks. Shouting instructions often is unproductive. Therefore, encourage parents and teachers to use clear and concise instructions with supplementary visual tools to aid these children. When providing instructions in classrooms, teachers should look directly at the student and call him (her) by name. It also can be helpful to have the student repeat the instructions. Seating students with ADHD near the front of the classroom, close to the teacher and away from other distracting students, can improve their focus and allow the teacher to more easily give nonverbal cues, such as tapping on the student’s desk if his attention is waning.

Hyperactivity. Children with ADHD are prone to excessive talkativeness and continuous motor movement; therefore, sitting still for long periods can be exceptionally difficult. Teachers and caregivers should keep assignments short. For students whose primary manifestation of ADHD is hyperactivity, sitting near the back of the classroom will allow them to stand and stretch without disrupting the class. Occasionally giving these students a time-limited, acceptable outlet for their urge to move may be beneficial.

Impulsivity. Children who exhibit this symptom are more focused on the present and have difficulty weighing the consequences of their actions. Allowing these children to take frequent breaks (eg, more play time) will let their brains rest and recharge so that they can take a step back to evaluate the outcomes of their actions. Instruct parents and teachers to give children with ADHD regular verbal or written feedback to monitor and modify behaviors over time. Consequences for not following the rules should be immediate and consistent.

Organization. School assignments require sequencing, planning, and time management. Therefore, having daily visual reminders of prioritized assignments and schedules is helpful for children with ADHD, both at school and at home. Teachers and parents can help children stay organized by checking and reviewing the child’s agenda with him several times a day; this will allow him more time to think about what he needs to do to complete assignments.Emotional reactivity. Children with ADHD become frustrated easily and often are particularly sensitive to disappointment because of the continuous redirection they receive. Normalizing their mistakes by reinforcing that everyone makes mistakes and teaching them to learn from their mistakes can help reduce their embarrassment.

It also can be helpful to identify triggers for emotional reactivity. Parents and teachers should minimize the amount of talking when a child is unable to control his emotions. Helping children label their emotions, developing strategies for when they become upset, and outlining clear consequences for unacceptable behaviors can help modify their reactions.

Attention-deficit/hyperactivity disorder (ADHD) affects 5% of children and adolescents worldwide.¹ Children with ADHD commonly have trouble with attention, hyperactivity, impulsivity, organization, and emotional reactivity, and these difficulties can result in behaviors that frustrate, worry, and overwhelm parents, teachers, and other caregivers.

Extensive evidence supports stimulants as a first-line treatment. However, nonpharmacologic interventions are important, yet often overlooked, adjuncts that can be helpful for children who have a partial response to stimulants or are not prescribed medication. Teaching caregivers to use the following interventions will allow them to help children better navigate situations that require managing their symptoms, such as in a classroom setting.²

Attention. Children with ADHD typically find it challenging to prioritize what to focus on, sustain that focus, and switch between tasks. Shouting instructions often is unproductive. Therefore, encourage parents and teachers to use clear and concise instructions with supplementary visual tools to aid these children. When providing instructions in classrooms, teachers should look directly at the student and call him (her) by name. It also can be helpful to have the student repeat the instructions. Seating students with ADHD near the front of the classroom, close to the teacher and away from other distracting students, can improve their focus and allow the teacher to more easily give nonverbal cues, such as tapping on the student’s desk if his attention is waning.

Hyperactivity. Children with ADHD are prone to excessive talkativeness and continuous motor movement; therefore, sitting still for long periods can be exceptionally difficult. Teachers and caregivers should keep assignments short. For students whose primary manifestation of ADHD is hyperactivity, sitting near the back of the classroom will allow them to stand and stretch without disrupting the class. Occasionally giving these students a time-limited, acceptable outlet for their urge to move may be beneficial.

Impulsivity. Children who exhibit this symptom are more focused on the present and have difficulty weighing the consequences of their actions. Allowing these children to take frequent breaks (eg, more play time) will let their brains rest and recharge so that they can take a step back to evaluate the outcomes of their actions. Instruct parents and teachers to give children with ADHD regular verbal or written feedback to monitor and modify behaviors over time. Consequences for not following the rules should be immediate and consistent.

Organization. School assignments require sequencing, planning, and time management. Therefore, having daily visual reminders of prioritized assignments and schedules is helpful for children with ADHD, both at school and at home. Teachers and parents can help children stay organized by checking and reviewing the child’s agenda with him several times a day; this will allow him more time to think about what he needs to do to complete assignments.Emotional reactivity. Children with ADHD become frustrated easily and often are particularly sensitive to disappointment because of the continuous redirection they receive. Normalizing their mistakes by reinforcing that everyone makes mistakes and teaching them to learn from their mistakes can help reduce their embarrassment.

It also can be helpful to identify triggers for emotional reactivity. Parents and teachers should minimize the amount of talking when a child is unable to control his emotions. Helping children label their emotions, developing strategies for when they become upset, and outlining clear consequences for unacceptable behaviors can help modify their reactions.

Most psychiatrists are required to sign an employment contract before taking a job, but few of us have received any training on reviewing such contracts. We often rely on coworkers and attorneys to navigate this process for us. However, the contract is crucial, because it outlines your employer’s clinical and administrative expectations for the position, and it gives you the opportunity to lay out what you want.¹ Because an employment contract is legally binding, you should thoroughly read it and look for clauses that may not work in your best interest. Although not a complete list, the following items should be reviewed before signing a contract.^1,2
 

Benefits. Make sure you are offered a reasonable salary, but balance the dollar amount with benefits such as:

• continuing medical education allowances
• educational loan forgiveness
• health/malpractice/disability insurance
• retirement benefits
• compensation for call schedule.

In some cases, there may be a delay before you are eligible to obtain certain benefits.

Work expectations. Many contracts state that the position is “full-time” or have other nonspecific parameters for work expectations. You should inquire about objective work parameters, such as duty hours, the average frequency of the current call schedule, timeframe for completing medical documentation, and penalties for not meeting clinical or administrative requirements, so you are not surprised by:

• working longer-than-planned shifts
• performing on-call duties
• working on days that you were not expecting
• having your credentialing status placed in jeopardy.

Some group practices allow for a half-day of no scheduled appointments with patients, so you can complete paperwork and return phone calls.

Noncompete clause. This restricts you from working within a certain geographic area or for a competing employer for a finite time period after the contract terminates or expires. A noncompete clause could restrict you from practicing within a large geographical area, especially if the job is located in a densely populated area. Some noncompete clauses do not include a temporal or geographic restriction, but can limit your ability to bring patients with you to a new practice or facility when the contract expires.

Malpractice insurance. Two types of malpractice insurance are occurrence and claims-made:

• Occurrence insurance protects you whenever an action is brought against you, even if the action is brought after the contract terminates or expires.
• Claims-made insurance provides coverage if the policy with the same insurer was in effect when the malpractice was committed and when the actual action was commenced.

Although claims-made insurance is less expensive, it can leave you without coverage should you leave your employer and no longer maintain the same insurance policy. Claims-made can be converted into occurrence through the purchase of a tail endorsement. If the employer does not offer you tail coverage, then it is your responsibility to pay for this insurance, which can be expensive.

Termination language. Every contract features a termination section that lists potential causes for terminating your employment. This list is usually not exhaustive, but it sets the framework for a realistic view of reasonable causes. Contracts also commonly contain provisions that permit termination “without cause” after notice of termination is provided. Although you could negotiate for more notice time, “without cause” clauses are unlikely to be removed from the contract.

Most psychiatrists are required to sign an employment contract before taking a job, but few of us have received any training on reviewing such contracts. We often rely on coworkers and attorneys to navigate this process for us. However, the contract is crucial, because it outlines your employer’s clinical and administrative expectations for the position, and it gives you the opportunity to lay out what you want.¹ Because an employment contract is legally binding, you should thoroughly read it and look for clauses that may not work in your best interest. Although not a complete list, the following items should be reviewed before signing a contract.^1,2
 

Benefits. Make sure you are offered a reasonable salary, but balance the dollar amount with benefits such as:

• continuing medical education allowances
• educational loan forgiveness
• health/malpractice/disability insurance
• retirement benefits
• compensation for call schedule.

In some cases, there may be a delay before you are eligible to obtain certain benefits.

Work expectations. Many contracts state that the position is “full-time” or have other nonspecific parameters for work expectations. You should inquire about objective work parameters, such as duty hours, the average frequency of the current call schedule, timeframe for completing medical documentation, and penalties for not meeting clinical or administrative requirements, so you are not surprised by:

• working longer-than-planned shifts
• performing on-call duties
• working on days that you were not expecting
• having your credentialing status placed in jeopardy.

Some group practices allow for a half-day of no scheduled appointments with patients, so you can complete paperwork and return phone calls.

Noncompete clause. This restricts you from working within a certain geographic area or for a competing employer for a finite time period after the contract terminates or expires. A noncompete clause could restrict you from practicing within a large geographical area, especially if the job is located in a densely populated area. Some noncompete clauses do not include a temporal or geographic restriction, but can limit your ability to bring patients with you to a new practice or facility when the contract expires.

Malpractice insurance. Two types of malpractice insurance are occurrence and claims-made:

• Occurrence insurance protects you whenever an action is brought against you, even if the action is brought after the contract terminates or expires.
• Claims-made insurance provides coverage if the policy with the same insurer was in effect when the malpractice was committed and when the actual action was commenced.

Although claims-made insurance is less expensive, it can leave you without coverage should you leave your employer and no longer maintain the same insurance policy. Claims-made can be converted into occurrence through the purchase of a tail endorsement. If the employer does not offer you tail coverage, then it is your responsibility to pay for this insurance, which can be expensive.

Termination language. Every contract features a termination section that lists potential causes for terminating your employment. This list is usually not exhaustive, but it sets the framework for a realistic view of reasonable causes. Contracts also commonly contain provisions that permit termination “without cause” after notice of termination is provided. Although you could negotiate for more notice time, “without cause” clauses are unlikely to be removed from the contract.

Most psychiatrists are required to sign an employment contract before taking a job, but few of us have received any training on reviewing such contracts. We often rely on coworkers and attorneys to navigate this process for us. However, the contract is crucial, because it outlines your employer’s clinical and administrative expectations for the position, and it gives you the opportunity to lay out what you want.¹ Because an employment contract is legally binding, you should thoroughly read it and look for clauses that may not work in your best interest. Although not a complete list, the following items should be reviewed before signing a contract.^1,2
 

Benefits. Make sure you are offered a reasonable salary, but balance the dollar amount with benefits such as:

• continuing medical education allowances
• educational loan forgiveness
• health/malpractice/disability insurance
• retirement benefits
• compensation for call schedule.

In some cases, there may be a delay before you are eligible to obtain certain benefits.

Work expectations. Many contracts state that the position is “full-time” or have other nonspecific parameters for work expectations. You should inquire about objective work parameters, such as duty hours, the average frequency of the current call schedule, timeframe for completing medical documentation, and penalties for not meeting clinical or administrative requirements, so you are not surprised by:

• working longer-than-planned shifts
• performing on-call duties
• working on days that you were not expecting
• having your credentialing status placed in jeopardy.

Some group practices allow for a half-day of no scheduled appointments with patients, so you can complete paperwork and return phone calls.

Noncompete clause. This restricts you from working within a certain geographic area or for a competing employer for a finite time period after the contract terminates or expires. A noncompete clause could restrict you from practicing within a large geographical area, especially if the job is located in a densely populated area. Some noncompete clauses do not include a temporal or geographic restriction, but can limit your ability to bring patients with you to a new practice or facility when the contract expires.

Malpractice insurance. Two types of malpractice insurance are occurrence and claims-made:

• Occurrence insurance protects you whenever an action is brought against you, even if the action is brought after the contract terminates or expires.
• Claims-made insurance provides coverage if the policy with the same insurer was in effect when the malpractice was committed and when the actual action was commenced.

Although claims-made insurance is less expensive, it can leave you without coverage should you leave your employer and no longer maintain the same insurance policy. Claims-made can be converted into occurrence through the purchase of a tail endorsement. If the employer does not offer you tail coverage, then it is your responsibility to pay for this insurance, which can be expensive.

Termination language. Every contract features a termination section that lists potential causes for terminating your employment. This list is usually not exhaustive, but it sets the framework for a realistic view of reasonable causes. Contracts also commonly contain provisions that permit termination “without cause” after notice of termination is provided. Although you could negotiate for more notice time, “without cause” clauses are unlikely to be removed from the contract.

Physical assaults by patients are an occupational hazard of practicing medicine. Assaults can happen in any clinical setting, occur unexpectedly, and have a lasting impact on all involved. In an anonymous survey of 11,000 hospital workers, 18.8% reported being physically assaulted.¹ Psychiatric clinicians may be at greater risk for violence than those who work in other specialties. In a survey of 380 health care employees who worked in a psychiatric setting, 40% of physicians reported being victims of a physical assault.^2,3 Although there are no guidelines on how to manage the aftermath of being assaulted by a patient, we offer the following advice based on our experiences.

Remain calm. Although it may be difficult to do so immediately after being assaulted, remaining calm is essential. You may experience a myriad of emotions, such as anger, fear, vulnerability, shock, or guilt. Although these responses are normal, they can hinder your ability to accomplish subsequent tasks.

Recall the assault. Despite the unpleasantness of replaying the incident, recall as many details as you can and immediately write them down. Because of the copious amount of paperwork you may be required to file (eg, incident reports, employee health forms) and statements that you will likely repeat, having an accurate version of what happened is paramount to determining a course of action. You also may be required to give a statement to law enforcement officials.

Report the assault to your supervisor(s). Informing supervisors and colleagues of what happened could begin the implementation of corrective measures to decrease the risk of future assaults.

Talk about the incident with coworkers, supervisors, and friends to help process what happened, normalize what you are experiencing, and allow others to learn from you. Being assaulted can be traumatic and can result in experiencing post-assault symptoms, such as disruptions in sleep patterns, changes in appetite, and nightmares of the incident. These can be normal reactions to what is an abnormal situation. If necessary, seek medical assistance.

Evaluate the circumstances. Although you may not be at fault, consider if there may have been contributing factors:

• Were there signs of escalating aggressiveness in the patient’s behavior that you may have missed?
• Would the presence of a chaperone during interactions with the patient have reduced the risk of an assault?
• Did you maintain a safe distance from the patient?
• Were existing safety policies followed?

Examine your surroundings. Could the surroundings where the assault occurred have hindered your ability to escape? If so, can they be altered to increase your chance of escaping? Are there items that could be used as potential weapons and should be removed?Expect changes to processes and procedures as part of the reverberations after an assault. Your firsthand account of the assault can limit staff overreactions by analyzing whether existing policies were appropriately implemented, before deeming them ineffective and enacting new policies.

Physical assaults by patients are an occupational hazard of practicing medicine. Assaults can happen in any clinical setting, occur unexpectedly, and have a lasting impact on all involved. In an anonymous survey of 11,000 hospital workers, 18.8% reported being physically assaulted.¹ Psychiatric clinicians may be at greater risk for violence than those who work in other specialties. In a survey of 380 health care employees who worked in a psychiatric setting, 40% of physicians reported being victims of a physical assault.^2,3 Although there are no guidelines on how to manage the aftermath of being assaulted by a patient, we offer the following advice based on our experiences.

Remain calm. Although it may be difficult to do so immediately after being assaulted, remaining calm is essential. You may experience a myriad of emotions, such as anger, fear, vulnerability, shock, or guilt. Although these responses are normal, they can hinder your ability to accomplish subsequent tasks.

Recall the assault. Despite the unpleasantness of replaying the incident, recall as many details as you can and immediately write them down. Because of the copious amount of paperwork you may be required to file (eg, incident reports, employee health forms) and statements that you will likely repeat, having an accurate version of what happened is paramount to determining a course of action. You also may be required to give a statement to law enforcement officials.

Report the assault to your supervisor(s). Informing supervisors and colleagues of what happened could begin the implementation of corrective measures to decrease the risk of future assaults.

Talk about the incident with coworkers, supervisors, and friends to help process what happened, normalize what you are experiencing, and allow others to learn from you. Being assaulted can be traumatic and can result in experiencing post-assault symptoms, such as disruptions in sleep patterns, changes in appetite, and nightmares of the incident. These can be normal reactions to what is an abnormal situation. If necessary, seek medical assistance.

Evaluate the circumstances. Although you may not be at fault, consider if there may have been contributing factors:

• Were there signs of escalating aggressiveness in the patient’s behavior that you may have missed?
• Would the presence of a chaperone during interactions with the patient have reduced the risk of an assault?
• Did you maintain a safe distance from the patient?
• Were existing safety policies followed?

Examine your surroundings. Could the surroundings where the assault occurred have hindered your ability to escape? If so, can they be altered to increase your chance of escaping? Are there items that could be used as potential weapons and should be removed?Expect changes to processes and procedures as part of the reverberations after an assault. Your firsthand account of the assault can limit staff overreactions by analyzing whether existing policies were appropriately implemented, before deeming them ineffective and enacting new policies.

Physical assaults by patients are an occupational hazard of practicing medicine. Assaults can happen in any clinical setting, occur unexpectedly, and have a lasting impact on all involved. In an anonymous survey of 11,000 hospital workers, 18.8% reported being physically assaulted.¹ Psychiatric clinicians may be at greater risk for violence than those who work in other specialties. In a survey of 380 health care employees who worked in a psychiatric setting, 40% of physicians reported being victims of a physical assault.^2,3 Although there are no guidelines on how to manage the aftermath of being assaulted by a patient, we offer the following advice based on our experiences.

Remain calm. Although it may be difficult to do so immediately after being assaulted, remaining calm is essential. You may experience a myriad of emotions, such as anger, fear, vulnerability, shock, or guilt. Although these responses are normal, they can hinder your ability to accomplish subsequent tasks.

Recall the assault. Despite the unpleasantness of replaying the incident, recall as many details as you can and immediately write them down. Because of the copious amount of paperwork you may be required to file (eg, incident reports, employee health forms) and statements that you will likely repeat, having an accurate version of what happened is paramount to determining a course of action. You also may be required to give a statement to law enforcement officials.

Report the assault to your supervisor(s). Informing supervisors and colleagues of what happened could begin the implementation of corrective measures to decrease the risk of future assaults.

Talk about the incident with coworkers, supervisors, and friends to help process what happened, normalize what you are experiencing, and allow others to learn from you. Being assaulted can be traumatic and can result in experiencing post-assault symptoms, such as disruptions in sleep patterns, changes in appetite, and nightmares of the incident. These can be normal reactions to what is an abnormal situation. If necessary, seek medical assistance.

Evaluate the circumstances. Although you may not be at fault, consider if there may have been contributing factors:

• Were there signs of escalating aggressiveness in the patient’s behavior that you may have missed?
• Would the presence of a chaperone during interactions with the patient have reduced the risk of an assault?
• Did you maintain a safe distance from the patient?
• Were existing safety policies followed?

Examine your surroundings. Could the surroundings where the assault occurred have hindered your ability to escape? If so, can they be altered to increase your chance of escaping? Are there items that could be used as potential weapons and should be removed?Expect changes to processes and procedures as part of the reverberations after an assault. Your firsthand account of the assault can limit staff overreactions by analyzing whether existing policies were appropriately implemented, before deeming them ineffective and enacting new policies.

As psychiatrists, we all come across patients who press our buttons and engender negative feelings, such as anger, frustration, and inadequacy.¹ These patients have been referred to as “hateful” or “difficult” because they disrupt the treatment alliance.^1,2 We are quick to point our fingers at such patients for making our jobs harder, being noncompliant, resisting the therapeutic alliance, and in general, being “problem patients.”³ However, the physician–patient relationship is a 2-way street. Although our patients knowingly or unknowingly play a role in this dynamic, we could be overlooking our role in adversely affecting this relationship. The following factors influence the physician–patient bond.^1,2

Countertransference. We may have negative feelings toward a patient based on our personalities and/or if the patient reminds us of someone we may not like, which could lead us to overprescribe or under­prescribe medications, conduct unnecessary medical workups, distance ourselves from the patient, etc. Accepting our disdain for certain patients and understanding why we have these emotions will allow us to better understand them, ensure that we are not impeding the delivery of appropriate clinical care, and improve rapport.

Listening. It may seem obvious that not listening to our patients negatively impacts rapport. However, in today’s technological world, we may not be really listening to our patients even when we think we are. Answering a text message or reading the patient’s electronic medical record while they are talking to us may increase productivity, but doing so also can interfere with our ability to form a therapeutic alliance. Although we may hear what our patients are saying, such distractions can create a hurdle in listening to what they are telling us.

Empathy often is confused for sympathy. Sympathy entails expressing concern and compassion for one’s distress, whereas empathy includes recognizing and sharing the patient’s emotions. Identifying with and understanding our patients’ situations, drives, and feelings allows us to understand what they are experiencing, see why they are reacting in a negative manner, and protect them from unnecessary emotional distress. Empathy can lead us to know what needs to be said and what should be said. It also can demystify a patient’s suffering. Not providing empathy or substituting sympathy can disrupt the therapeutic alliance.

Projective identification. Patients can project intolerable and negative feelings onto us and coerce us into identifying with what has been projected, allowing them to indirectly take control of our emotions. Our subsequent reactions can unsettle the physician–patient relationship. We need to be attuned to this process and recognize what the patient is provoking within us. Once we understand the process, we can realize that this is how they deal with others under similarly stressful conditions, and then react in a more supportive and healthy manner, rather than reviling our patients and negatively impacting the therapeutic relationship.

As psychiatrists, we all come across patients who press our buttons and engender negative feelings, such as anger, frustration, and inadequacy.¹ These patients have been referred to as “hateful” or “difficult” because they disrupt the treatment alliance.^1,2 We are quick to point our fingers at such patients for making our jobs harder, being noncompliant, resisting the therapeutic alliance, and in general, being “problem patients.”³ However, the physician–patient relationship is a 2-way street. Although our patients knowingly or unknowingly play a role in this dynamic, we could be overlooking our role in adversely affecting this relationship. The following factors influence the physician–patient bond.^1,2

Countertransference. We may have negative feelings toward a patient based on our personalities and/or if the patient reminds us of someone we may not like, which could lead us to overprescribe or under­prescribe medications, conduct unnecessary medical workups, distance ourselves from the patient, etc. Accepting our disdain for certain patients and understanding why we have these emotions will allow us to better understand them, ensure that we are not impeding the delivery of appropriate clinical care, and improve rapport.

Listening. It may seem obvious that not listening to our patients negatively impacts rapport. However, in today’s technological world, we may not be really listening to our patients even when we think we are. Answering a text message or reading the patient’s electronic medical record while they are talking to us may increase productivity, but doing so also can interfere with our ability to form a therapeutic alliance. Although we may hear what our patients are saying, such distractions can create a hurdle in listening to what they are telling us.

Empathy often is confused for sympathy. Sympathy entails expressing concern and compassion for one’s distress, whereas empathy includes recognizing and sharing the patient’s emotions. Identifying with and understanding our patients’ situations, drives, and feelings allows us to understand what they are experiencing, see why they are reacting in a negative manner, and protect them from unnecessary emotional distress. Empathy can lead us to know what needs to be said and what should be said. It also can demystify a patient’s suffering. Not providing empathy or substituting sympathy can disrupt the therapeutic alliance.

Projective identification. Patients can project intolerable and negative feelings onto us and coerce us into identifying with what has been projected, allowing them to indirectly take control of our emotions. Our subsequent reactions can unsettle the physician–patient relationship. We need to be attuned to this process and recognize what the patient is provoking within us. Once we understand the process, we can realize that this is how they deal with others under similarly stressful conditions, and then react in a more supportive and healthy manner, rather than reviling our patients and negatively impacting the therapeutic relationship.

As psychiatrists, we all come across patients who press our buttons and engender negative feelings, such as anger, frustration, and inadequacy.¹ These patients have been referred to as “hateful” or “difficult” because they disrupt the treatment alliance.^1,2 We are quick to point our fingers at such patients for making our jobs harder, being noncompliant, resisting the therapeutic alliance, and in general, being “problem patients.”³ However, the physician–patient relationship is a 2-way street. Although our patients knowingly or unknowingly play a role in this dynamic, we could be overlooking our role in adversely affecting this relationship. The following factors influence the physician–patient bond.^1,2

Countertransference. We may have negative feelings toward a patient based on our personalities and/or if the patient reminds us of someone we may not like, which could lead us to overprescribe or under­prescribe medications, conduct unnecessary medical workups, distance ourselves from the patient, etc. Accepting our disdain for certain patients and understanding why we have these emotions will allow us to better understand them, ensure that we are not impeding the delivery of appropriate clinical care, and improve rapport.

Listening. It may seem obvious that not listening to our patients negatively impacts rapport. However, in today’s technological world, we may not be really listening to our patients even when we think we are. Answering a text message or reading the patient’s electronic medical record while they are talking to us may increase productivity, but doing so also can interfere with our ability to form a therapeutic alliance. Although we may hear what our patients are saying, such distractions can create a hurdle in listening to what they are telling us.

Empathy often is confused for sympathy. Sympathy entails expressing concern and compassion for one’s distress, whereas empathy includes recognizing and sharing the patient’s emotions. Identifying with and understanding our patients’ situations, drives, and feelings allows us to understand what they are experiencing, see why they are reacting in a negative manner, and protect them from unnecessary emotional distress. Empathy can lead us to know what needs to be said and what should be said. It also can demystify a patient’s suffering. Not providing empathy or substituting sympathy can disrupt the therapeutic alliance.

Projective identification. Patients can project intolerable and negative feelings onto us and coerce us into identifying with what has been projected, allowing them to indirectly take control of our emotions. Our subsequent reactions can unsettle the physician–patient relationship. We need to be attuned to this process and recognize what the patient is provoking within us. Once we understand the process, we can realize that this is how they deal with others under similarly stressful conditions, and then react in a more supportive and healthy manner, rather than reviling our patients and negatively impacting the therapeutic relationship.