Outpatient Thursdays
Staying up late charting to give myself a real four-day weekend, I am thankful for the art. Last week’s clinic was busy. Outpatient days tend toward themes. Maybe it’s just my superstition, but I’ll have a good run of Effexor-for-TBI mornings or dementia with depression or caregiver fatigue or post-meth psychosis. Sometimes three four cases in a row.
The theme of last Thursday was that a lot of my patients are WELL. Like work-and-love making-hay-while-the-sun-shines all-the-way-well WELL.
It was rad.
A late bloomer and long-time bachelor, my fear-of-commitment issues meant that by the time a facility printed my name on the narc scripts I’d probably have already taken another job. I think I was privileged at 13 hospitals before I was 40.
My bachelor years were 90 percent inpatient. I’d see whoever was on my list, and if I wrote a note on a Friday, I never got too broke up if they or I were somewhere else by Monday. I lived out of my car and at various VRBOs, hotels, and guest rooms. I bought a Ducati. I went to Patagonia and Ireland. I had a really sweet rental on Oriental Parade in Wellington, New Zealand. Then I was like, Houts, this is not a career. Go back to Maryland, where you were happy. Settle down.
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At the West Baltimore VA, I met Joe Schwartz. I think I’d met him a couple times before, but he couldn’t remember, either. Joe is like that. He knows that you know that it’s OK that neither of you know, you know? Joe was full of great aphorisms like, “I wish I’d never met you, Houts.” And in his kindest tone after a lunch punctuated by Sriracha pulled from his desk drawer in the C-Suite, Joe could get Socratic and ask, “What does it mean? A rolling stone gathers no moss?” at which point I would point out the pros of short-term leases and of doing inpatient work, but then Joe would laugh and cry, “No! Moss is GOOD! Moss is SOFT! Moss is GREEN!” I forget what he said after that. Something about how my future father-in-law would be on the board of a way-cool community psych foundation, and married-Houts life would include a concrete guy, a variety of babysitters sourced from a powerlifting gym who look like young phone operators from the John Wick series, a custom cabinet maker Up North who is a friend of a friend, and a guitar player in Anchorage. And the guy who founded the really cool community psych foundation in the ’70s will co-coach your kids’ chess club with you.
I gotta admit. Moss is pretty cush.
As I settled into married life in Minneapolis and got a mortgage and started banking money at a government job into an account dedicated to childcare, I figured it was time to get my outpatient chops back.
I didn’t know until it was my job to hire psychiatrists that, often, inpatient and outpatient docs are different animals. Inpatient docs need to know exactly how many hours a patient slept. They love aggressive med titrations and have memorized the House Of God rules and know that the first responsibility is to make an egregiously brief length of stay somehow instrumental in averting crisis. Inpatient docs are 24-valve motors that like to be revved. When I did a lot of that work, I administratively discharged patients and won all my doc-to-docs and worked 15 days in a row. I was an inpatient machine. And bored out of my mind.
Outpatient work is more like sailing than powerboating. Outpatients don’t come with an official Medication Administration Record. Outpatients lie. Outpatients sell their pills. Outpatients do drugs. Outpatients are late. Outpatients no-show. Outpatients won’t get out of your office. And when they throw things, there aren’t any beefy inpatient security personnel to just take care of that nonsense already.
But outpatients, if you’re good to them, may stay with you forever, which allows for asymptotic progress.
I thought I was an inpatient doc. But really I’m an outpatient doc. I thought I was a bicoastal elite. Guess I’m a Midwesterner. And that’s cool because I’ve gotten a couple dozen people totally off a ridiculous amount of benzos, and I’ve gotten a few off of SSDI, and I’m always diagnosing akathisia that three other psychiatrists missed, and my front desk knows that they never have to ask me if I’ll take a case, because I’ll always say yes, even though I’m also kind of a dick insofar as that I may also quip, “You never have to ask me. It’s a waste of your time and mine. May I hang up now?” (Don’t worry. I speak Minnesotan better these days, and they’re used to me.)
So. On this Thanksgiving of 2024, I ask a question I love the answer to. You know what you get when you see a metric ton of patients over a long time with great supervision? You get really good at your job. And for that I am thankful.
