MARA GOVERMAN: You want to help every family that calls, but your schedule's full, and the need keeps growing. What can you do when you can't take another patient? In this episode, we will talk about how to manage referrals, support other providers, and build systems that make a difference even when you have to say no. 

JOSH FEDER: I'm Dr. Josh Feder, the editor-in-chief of The Carlat Child Psychiatry Report and co-author of the Child Medication Fact book for Psychiatric Practice, second edition 2023, and our other book, Prescribing Psychotropics.  

MARA GOVERMAN: And I’m Mara Goverman, a licensed clinical social worker in Southern California with a private practice, and an avid reader of The Carlat Psychiatry Reports. Today, we are talking about something that almost every mental health provider in child and adolescent care runs into: too many referrals and not enough capacity.  

JOSH FEDER: Right now, the number of trained child psychiatrists in the US sits around 8,300.  Meanwhile, more than 15 million kids and teens meet the criteria for a psychiatric diagnosis. That's about one in five(http://www.tinyurl.com/58wcu4bj).

MARA GOVERMAN: And the gaps hit hardest in rural areas and communities with fewer resources. It raises a question that providers face constantly: which referrals do you take, and what do you do with the ones you can't?  

JOSH FEDER: Yeah, so, let's start there. One of the first things clinicians can do is clarify their scope, what kinds of patients they're set up to see, what treatments they offer, and what their capacity looks like for new referrals. That kind of clarity can shape what gets accepted and what's redirected,  

MARA GOVERMAN: And that redirection matters. Families are often left hanging when they hear, “I'm not accepting new patients.” A better approach is to build a plan. What do you say? Where do you point them to? What resources can you share?  

JOSH FEDER: Even if you can't take them yourself, you can give them the next step that might be a referral list, ideally, with at least three names, so it doesn't feel like a medical recommendation that you're liable for if something doesn't go well, or it might be crisis numbers for more urgent cases.  

MARA GOVERMAN: And that list? It helps to include a mix. You might include providers who take insurance, some who offer specialty care, and others who handle more general needs. It could include therapists, NPs, developmental pediatricians, and PCPs with an interest in mental health. 

JOSH FEDER: Some clinicians keep a voicemail message or auto reply that gives families information up front, whether they're taking new patients and where to turn if they're not, that reduces the back and forth and gives families quicker direction.  

MARA GOVERMAN: It is also okay to say, “This is out of my scope.”, especially if the referral seems routine.  A child with uncomplicated ADHD, anxiety, or depression might not need a psychiatrist. You can refer them to a PCP, a therapist, or a psychologist for testing.  

JOSH FEDER: Let's talk about how to make those referrals smoother. What helps you trust a handoff? And it's really important because when we think about our training, ADHD, anxiety, depression, those can be bread and butter in some ways, and if they're mishandled by somebody who's not a psychiatrist, then they may end up with us later. But you're right, Mara, we just can't take all of those referrals. I get so many referrals every day, and you get into the habit of saying, “I'm so sorry.” It's not easy, it really isn't. I mean, for my own practice, I've had a system for a number of years where I have a voicemail that says, please go to my website and give me the information, and do that through my contact button. And that, when people actually do that, is really helpful because then I can look at what their difficulty is and then, like we've talked about, I have a list of referrals. Sometimes it's for psychological testing, sometimes it's for therapy, and a lot of times it's for a colleague psychiatrist who might be in a better place to take those referrals. 

MARA GOVERMAN: So, what you're also suggesting is that you start building and updating your referral list the day you open your door.  

JOSH FEDER: And you know what? I do this and I tell colleagues to do it, but when we put this article in Carlat, what was it last summer or something? I got a lot of pushback from my review board, saying clinicians don't have time to build and cultivate lists and respond to everybody who calls, and I respect that. Not everybody's going to be able to do that. It works for me, but maybe something different works for other people.  

MARA GOVERMAN: Another thing providers can do is develop a basic referral letter template. Something you can personalize with diagnosis, what treatments have been tried, what worked, and what you recommend moving forward,  that's helpful for families and receiving providers.  

JOSH FEDER: I do that a lot. So, I'm in a phase of my career where I'm referring a lot of people out now who I've been seeing for a number of years, and a lot of them are stable, and they could be seeing a primary care doctor or nurse practitioner, or somebody else, to just continue. And I have a standard format for a relatively brief letter. That's what gets read anyway. If you write a long report, a lot of times people don't read it. And I just go through and I have the name and the birthdate and how long I've been seeing them and the diagnoses that we've been working on, and the things that seem to have worked for them, biopsychosocial, all the things that have been working a little bit about the course of care, the whole thing's done in a couple paragraphs. And it's really helpful for the receiving doc, and for some people, I'm going to make it a warm handoff and call that receiving person if they have somebody. If you're in a setting where a program is ending, like an IOP or a schooling service, which has a timeframe, and then people complete it, and then they go off to something else, you probably need a plan for transitioning patients, and that's another spot where a summary and clear recommendations help the next provider to pick up the thread. 

JOSH FEDER: So while we're talking about not taking patients who might be, in a way, too simple for us to be taking on. I mean, we really should be taking the more complex kids. It is important to have a caseload of people whom you're able to see over time, watch them develop, maybe do therapy with them, and as they grow, you get to see them do new things and take on the world. And so that's one of the joys of practice. And while we can't burn ourselves out by taking every new referral of every child, and we can't keep every patient who we've been seeing because they probably should go to a different provider, and it's part of the joy of practice and preventing burnout to have a caseload of families that you follow over the years. Thoughts, Mara?


MARA GOVERMAN: You are wearing the hat of a practitioner who does not take insurance, and I would imagine that there are different challenges for many of our listeners who are under managed care or insurance plans and might not have that availability, but having worked with you for so many years and having the privilege of following many families, you also have to stay in your lane if your area of expertise and comfort is in a particular range you have to do a lot of self-reflection and check in to be sure that your standard of care is at its best so that you are serving your clients and giving them what they need to get to the next level.

JOSH FEDER: Let me pick up on that just for a second, because it does happen that
people developmentally move beyond where I would be continuing to care for them. So, for instance, I'm not currently taking couples therapy, right? So I might be doing therapy with someone, they get married, and now they're having couple's difficulties. Am I gonna turn it into a couple's therapy at this stage? No, I'm gonna refer them to somebody else to do that work. It's a really good point.

MARA GOVERMAN: Speaking of transitions, let's talk about stepping patients down. Some will do well enough that they no longer need specialty care. Others might ask to reduce visits for cost or convenience.

JOSH FEDER: And one approach is to ease up on appointment frequency.  Stretch out visits and see how they do. If they stay stable, consider transitioning to a primary care provider or behavioral health nurse practitioner, somebody like that. For some patients, you might also check in once a year, or be available for consults, and I do that often. People are done, they're done with me, but they can come back and say “Hi”. If something kind of goes south on them, their primary care person who's prescribing can gimme a call, something like that. We just got a call before we started recording today from a primary care doc who's doing the medications now. The person consults me periodically. They just had a change in their life, they gave me the heads up that I might be needed for a consult.  

MARA GOVERMAN: So, the word that keeps coming up is continuing to assess stability, especially when you're talking about patients who come out of an IOP and they're in a euphoric state, those tend to be the most dangerous times. So, you have to be very careful about assessment and appointment frequency at the beginning.  

JOSH FEDER: Right. So, people come out of programs, and then they kind of fall through the cracks. We don't want to see that happening, and I've seen that so often.

MARA GOVERMAN: And it helps to be upfront with families or at least be as honest as you can. They may want to stay in specialty care indefinitely, especially if they waited a long time to get there. It's okay to say, “Your care is going well, and you may not need this level of specialty care support anymore.”  

JOSH FEDER: So this is your specialty. Mara's got a busy practice, busier than she can stand sometimes, and she'll often be helping refer people. Being a little bit of a, you know, “Okay. It's time to do something different”, right? 

MARA GOVERMAN: Well, you know, there's that ethical dilemma of dependency, independence, and how do you weigh allowing people to stumble and try to figure that out without supporting? Not easy for me. Let's also discuss supporting non-psychiatrist prescribers. Pediatricians sometimes feel uneasy managing psych meds. They may worry about what happens if the child worsens or a new symptom shows up.  

JOSH FEDER: And clinicians can normalize that. You might say, “Here's what I'd monitor...”, like often abnormal involuntary movements, lipids, hemoglobin, stuff like that, blood pressure, or offer a one-time consult. Right? Some primary care providers get extra training through programs like the REACH Institute or local behavioral health collaboratives.  

MARA GOVERMAN: Organizations like the American Academy of Pediatrics provide step-by-step guidance for conditions like depression, anxiety, and ADHD(www.tinyurl.com/24ca7sp6). Many states also have psychiatric consultation programs for primary care. 

JOSH FEDER: Bottom line, no one provider can meet all the demand, but you can create systems that help you respond consistently, refer effectively, and support care across different levels of training.  

MARA GOVERMAN: And if those systems aren't in place yet, start small, build a referral list, update your voicemail, create a village, write one good handoff letter. Over time, those small moves make your practice more sustainable.  

JOSH FEDER: And they help build capacity across the whole community. And that's the long game, right? So, I mean, the idea here is we're trying to keep ourselves from getting burned out, and at the same time, provide as much care to as many people using our specialty skills, where they're needed and not, where they're not. That doesn't mean that you never take patients who are fun and easy follow-ups. I mean, not everything can be very, very complex and overwhelming, but you do need to titrate that if you're really going to do the most good for the most people in your career and preserve yourself at the same time.  Dr. Charmi Patel Rao’s article in our April/May/June 2024 newsletter is the inspiration for this podcast, and it contains additional resources on how to refer a patient. If you found this episode valuable, please share it with others who need to hear this message.  

MARA GOVERMAN: Everything from Carlat Publishing is independently researched and produced. There is no funding from the pharmaceutical industry.  

JOSH FEDER: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads, and our authors do not receive industry funding. That helps us to bring you unbiased information that you can trust.  

MARA GOVERMAN: Remember, we are all in this together. Stay informed, stay engaged, and let's continue the conversation.  

JOSH FEDER: Thanks for tuning in to The Carlat Psychiatry podcast. Until next time, take care and stay safe.