How I Plan to Get Out of a Rut in 2020

2019 has been a bit of a rut for me. Here’s what I plan to do to shake things up in 2020!

My accomplishments through the 2010’s:

December 2012 Completed BSN

February 2013 Passed NCLEX

March 2013 Started 1st nursing job

August 2014 Started BSN-DNP

December 2016 Completed MSN & Passed ANCC Boards

January 2017 Started 1st NP Job

July 2017 Completed DNP

March 2018 Opened Telepsychiatry Business

2019 *Crickets*

It’s a strange feeling. My entire life I focused on achieving the next academic success or the next best career move. Now my academic career is complete, my practice is as big as I want it… and what now? How do you mentally shift from measuring your success through academics and career achievements when that has been your measure of success for so long? In 2019 I have struggled to find my next move. Earlier this year I thought I would try medical writing and quickly realized I don’t have the knowledge or experience I would need for that. Then I thought I would try to break into the field of research. Again I realized that I don’t really have the knowledge or experience. What I am trained to do and what I do best is take care of patients. So, how do I grow from here? As I watch everyone else discuss their accomplishments from 2019 I realize that I have had no major accomplishments this year *Yikes*. I think 2019 has been a bit of a rut for me professionally. And being in that rut leaves me feeling burnt out. So, today, on this very last day of the decade I am going to make an action plan to get out of a rut in 2020.

My professional goals for 2020

Educate others and share my experiences. As I started blogging over the last week I began to feel a passion and excitement professionally that I haven’t felt in a long time. I realized I love teaching. I love sharing my experiences. I’m excited to carry this excitement into 2020.

Reevaluate my patient encounters. I currently do 15 minute medication checks. I’m going to research how to make these encounters more meaningful. On the practical side of that, I will see if I could maintain my current compensation by billing for longer appointments. I’m going to see how I can strike a balance between quality and quantity.

Study a new subspecialty. I am very interested in adding another subspecialty. There is a huge gap in the healthcare system between women’s health and mental health. I’m very curious to investigate and find new ways to help and educate my female patients. I’m also interested in weight loss within the mental health community. I don’t know if I can commit to becoming certified, but at the very least I would like to increase my knowledge about how to help my patients live healthier lifestyles.

My Personal Goals 2020

I have to say exercise, right? Isn’t that mandatory on this list? Seriously though, I attempted a good exercise routine multiple times in 2019 and it would stick for a few weeks and then fade away. I tried Orange Theory (which I absolutely loved by the way), but then I got tired of waking up at 5am (I am NOT a morning person at all). I got into a cycling routine for a bit and thoroughly enjoyed that, but it just kind of faded away too. So 2020 is the year to establish a routine. I don’t need it to be insane. I will take any routine I can get… more to come another time on what that routine will look like.

I will start a hobby. I have never had a hobby. EVER. I have been invested in academics for so long that all my mental energy went to writing papers, studying… all the school things. Now I am so used to spending all my time doing something I had to do, that I don’t know how to enjoy doing something just for the sake of doing it. I don’t know the hobby yet, but 2020 will be the year of hobby!

I have never put my goals in writing. So, here it is, published on the internet for everyone to see. At the end of 2020 I will come back and evaluate how I did! 2020 won’t be another rut year and I don’t need academic structure or a new career to make that happen! This is going to be a totally new experience for me and I will provide updates periodically on how it’s going.

Have you been in a rut recently? What are you going to do to make 2020 a better year? I’m open to any suggestions you might have to add to my list! I can’t wait to hear from you! Please leave your thoughts in the comments below and go to the home page to subscribe and get the latest content!

“Can I have time off work?” How I handle requests for extended leave of absence

Today we will discuss how I handle requests for an extended leave of absence as a psychiatric NP.

Welcome to post two! I’m so excited to see more people joining today! This one is going to be a doozy! But here we go… If you have been practicing as an NP (or PA – let’s include PAs here!) for any length of time, you have encountered it. A patient comes in for a first time appointment and as you go through the evaluation every question comes back to work.

“How have you been sleeping?” “Oh horrible, I’m so exhausted at work.”

“How is your concentration?” “Terrible, I can’t get anything done at work?”

“How’s your mood?” “Terrible, I can’t stand to be around my co-workers.”

You know what’s coming next. You get a lump in your throat as you attempt to finish the evaluation and the patient says, “Oh one more thing, can you fill out these forms for me? I need time off work.” AHHHHH!! You KNEW it was coming! You KNEW it! Nonetheless, the tension in the room mounts as you try to figure out what to do next…

There’s a couple of different scenarios that led to this moment. By the time the patient makes it to a psychiatric NP, it’s possible someone in primary care already saw them, gave them a few weeks off, and when they were not ready to return to work referred them to psychiatry for more intensive treatment. Or primary care referred them to psychiatry immediately. Or they have missed a lot of time at work for mental health symptoms and now they are seeking treatment for the first time since they have used up all of their sick leave and need to apply for FMLA and/or short term disability. Now the patient fully expects for their leave of absence (whether through FMLA or a short term disability claim) to be extended and for the time between their primary care referral and the time they made it to your office to be covered as well. WHAT?? Where in the world did they get this idea??

At this moment I am thinking SO MANY things. Why would you stop working prior to receiving this recommendation from a medical provider? How in the world would I be able to cover time off you missed before you were even my patient? WHY are we meeting for the first time and things are now so serious that your mental health concern is cause for “disability???”

You can say this sounds heartless. That’s okay. Once you have been faced with this situation 101 times you have to be start being a bit more objective. Don’t get me wrong, if an established patient needs medical leave, like REALLY needs medical leave, I am your number one advocate! If a new patient is truly ill enough to impair their ability to work, I’m here for you. If a patient needs time off work to seek more intensive treatment, I will absolutely go to bat for you. But let’s be honest… 95% or more of our patients seeking medical leave (at least in psychiatry or for psychiatric purposes) are not sick enough to merit taking an extended leave of absence from work.

So, what do I do next? First I have to shut down my personal feelings. My personal feelings are work is good for people. A busy and productive mind is a happy mind. I believe my patients need to be working, volunteering, doing something that gives them the opportunity to contribute to society (if at all possible) which will have a huge positive impact on their mental health. For this interaction I have to place these thoughts in the back of my mind.

Once I can shut down my personal feelings I start to EDUCATE. I have found education to be the savior in MANY difficult situations. I educate the patient on the purpose of FMLA and short term disability. I educate the patient on the process of applying and advise that MOST times the short term disability claims in mental health are denied so they may end up never getting reimbursed for their time off. I say, “Insurance companies approve or disapprove your time off, not your provider. I can make a recommendation, but ultimately it’s in the insurance company’s hands.” Then I dive into discussing the best way to treat their mental health concern (which is the whole reason they are in my office, right?). At this point, the patient believes the best way to treat their mental health concern is to take time off work. This thought has to be reframed and again we EDUCATE about what will REALLY help their mental health. We discuss medication, therapy, and more intensive treatment options. When I need to be VERY direct I say, “If your mental health concerns have become severe enough to merit a disability claim, then we also need to discuss inpatient treatment (or partial hospitalization treatment at the very least).” Treating a patient who is so severely mentally unstable that they cannot perform their job functions and need an extended leave of absence means that they are likely not a good candidate for traditional outpatient psychiatric services at this point in time. Outpatient treatment offers you a 15-20 minute visit with the NP/PA/MD biweekly or monthly and then weekly therapy (if a therapist is available, they can afford it, and/or their insurance will cover it). That is just not enough. If someone is seeking a leave of absence for medical reasons the person is likely having surgery, doing physical therapy, birthing a baby. They are doing something that requires their time and energy be invested in the healing process. Why should psychiatry be any different? Taking a leave of absence and dedicating only one hour a week (or less) to mental health treatment is simply not productive.

What happens next? Once I have given the patient all of this information the end result varies widely. If the patient was only seeking an extended leave of absence, they usually leave upset. If the patient is in need of help and ready to work toward recovery, I provide a list of partial hospitalization programs and my patient starts making calls that same day to start treatment. At the start of my career I had a VERY hard time saying no or delivering news people wouldn’t want to hear. So, on several occasions I gave in to patients who requested an extended leave of absence and let them refuse more intensive treatment. Do you know what happened? The patients met with me once every other week for the length of their time off, reported no change in their symptoms, and at the end of the leave of absence we were in no different shape than at the start. They requested another extension on their leave of absence over and over again. Most of the time these claims were denied and sadly once the leave of absence was over, so was the patients willingness to attend office visits. I quickly realized that telling the patient what they wanted to hear was not helping them at all. So, my methods changed. Once patients started engaging in partial hospitalization programming they raved about how beneficial it was and were more ready to return to work with new coping skills and a much better frame of mind. One patient even told me, “Everyone should have to go through this program when they start mental health treatment. It changed my life.” That’s when I realized that to really help people I might have to ruffle some feathers along the way.

So, now the patient has gone through treatment, they return to work, and they come back to you two weeks later and they are decompensating again? What then? It’s very important to decipher between a patient who has a mental illness that prevents them from working and one that dislikes their job. If a patient dislikes their job or their boss they won’t like the answer… find a new job.

What are your thoughts on handling short term disability claims in psychiatry or other specialties? How often are you faced with this? How do you handle it? Leave a comment below! I can’t wait to hear your thoughts! As always, thanks for joining!