Best CL fellowships?

[Blitz2006]

So I am wrapping up PGY1. I think I want to pursue CL.

Can you guys rank your top 10 CL fellowships?

And is doing a fellowship worth it, as I know there are CL psychiatrists who haven't done one...

Thanks!

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[Leo Aquarius]

Before we rank any CL fellowships, let's help you with the worth it question.

Yes, if you want to do CL as a faculty somewhere. Then you need the fellowship.

No, if you want to do CL in the general community.

Yes, if you want the expert knowledge.

No, if you want more money.

I wouldn't know where to begin in ranking them. Some very strong CL fellowships don't fill every year.

 

[Blitz2006]

Sounds good.

I would like to do a CL fellowship at a "prestigious" place to boost my CV.

I would like to work in a large academic setting in CL, as well as do private practice on the side.

I am assuming that having a prestigious name under my belt will help me to work as a CL psychiatrist in a place like Hopkins or Columbia, as well as help me to have a thriving private practice.

Is this correct or am I wasting a year of my life?

Before we rank any CL fellowships, let's help you with the worth it question.

Yes, if you want to do CL as a faculty somewhere. Then you need the fellowship.

No, if you want to do CL in the general community.

Yes, if you want the expert knowledge.

No, if you want more money.

I wouldn't know where to begin in ranking them. Some very strong CL fellowships don't fill every year.

 

[Shikima]

Wasting a year if you're going PP, but not academia.

 

[Blitz2006]

But doesn't have "big names" on CV help with generating strong patient base?

I am doing my residency here in NYC, and I am hearing about psychiatrists charging $500/hr cash only in the upper east side. But these guys have trained at places like Cornell and Columbia...

Wasting a year if you're going PP, but not academia.

 

[Asklepian]

erm doing a fellowship somewhere prestigious doesn't change where you went to medical school. which is what patients care about (if they care about that sort of thing at all). it's slightly disingenuous to market yourself as a "harvard trained psychiatrist" after spending a year doing a c/l fellowship at MGH or whatever but people do it all the time.

I would disagree with this statement. Learning your basic medicine in med school may be more important to some patients, but it definitely isn't a better indicator of how you practice your specialty. Residency and fellowship is where you learn the bread and butter of your trade, so I have a hard time seeing how undergraduate medical education trumps that.

 

[dl2dp2]

But doesn't have "big names" on CV help with generating strong patient base?

I am doing my residency here in NYC, and I am hearing about psychiatrists charging $500/hr cash only in the upper east side. But these guys have trained at places like Cornell and Columbia...

Getting $500 an hour is not as easy as you think, even if you trained at a top program. I wouldn't try to go for a CL fellowship as a way to do that kind of practice.

 

[Leo Aquarius]

They can charge $500 due to other reasons, NOT because they have a CL fellowship under their belt.

 

[Shikima]

But doesn't have "big names" on CV help with generating strong patient base?

I am doing my residency here in NYC, and I am hearing about psychiatrists charging $500/hr cash only in the upper east side. But these guys have trained at places like Cornell and Columbia...

In lies the ignorance of New Yorkers with far too much money on their hands. Try getting that much from people in Indiana or other places.... unlikely. You're going to rely on reimbursement from insurance companies and a wage from the hospital. You may want to examine what C&L is really like. It isn't boutique medicine.

 

[Blitz2006]

In lies the ignorance of New Yorkers with far too much money on their hands. Try getting that much from people in Indiana or other places.... unlikely. You're going to rely on reimbursement from insurance companies and a wage from the hospital. You may want to examine what C&L is really like. It isn't boutique medicine.

No I know its not boutqiue medicine. I've done 2 months of CL. I quite like CL for:

1) The ability to work closely with other specialities
2) I enjoy working in a general hospital setting (vs. psych inpatient)
3) I like the fast paced action of CL

I'm not going into CL for money. I actually want to do 2 fellowships (Neuropsych and CL). I'm not expecting to get rich of either of them. However, my question is, is doing fellowships (such as in CL) at a big name place beneficial for private practice? I would eventually like to do CL 8-5 and then perhaps do private practice on the side (week nights and weekends). Therefore, I was wondering if doing CL fellowship at a big name place would help my practice to 'flourish', for lack of better words?

 

[DJspreadsheet]

No I know its not boutqiue medicine. I've done 2 months of CL. I quite like CL for:

1) The ability to work closely with other specialities
2) I enjoy working in a general hospital setting (vs. psych inpatient)
3) I like the fast paced action of CL

I'm not going into CL for money. I actually want to do 2 fellowships (Neuropsych and CL). I'm not expecting to get rich of either of them. However, my question is, is doing fellowships (such as in CL) at a big name place beneficial for private practice? I would eventually like to do CL 8-5 and then perhaps do private practice on the side (week nights and weekends). Therefore, I was wondering if doing CL fellowship at a big name place would help my practice to 'flourish', for lack of better words?

All the things you claim to like aren't actually private practice outpatient psychiatry. If you want a big name on your resume to recruit cash-pay outpatients, why in the hell would you choose a fellowship that literally only applies to the inpatient setting? And forgive me for laughing at your assumption that 8-5 C/L actually ends at 5.

 

[Shikima]

All the things you claim to like aren't actually private practice outpatient psychiatry. If you want a big name on your resume to recruit cash-pay outpatients, why in the hell would you choose a fellowship that literally only applies to the inpatient setting? And forgive me for laughing at your assumption that 8-5 C/L actually ends at 5.

I was just about to call out the same.

 

[Blitz2006]

All the things you claim to like aren't actually private practice outpatient psychiatry. If you want a big name on your resume to recruit cash-pay outpatients, why in the hell would you choose a fellowship that literally only applies to the inpatient setting? And forgive me for laughing at your assumption that 8-5 C/L actually ends at 5.

Fair enough. So what about Neuropsych fellowship? Would that be helpful?

Sure, CL may finish at 6-7pm. There is an attending I work with that religiously finishes at around 4-5 pm, and does his PP afterwards. While it probably is not the norm, I guess it is possible.

 

[Blitz2006]

you seem to have some strange ideas. as i said before most pts don't care where you trained, it doesn't make a different to them in terms of practice, and those that do care more where you went to medical school (even if that doesn't make much sense). having a fellowship is not going to change any of that. the main way that particular residencies have graduates successful in pp is because they actually teach their residents how to establish a private practice and have a large voluntary faculty who are happy to mentor residents in doing so and possibly throw referrals their way.

but make no mistake, the beginning pp psychiatrist who went to columbia still gets the same crappy referrals as everyone else. it takes time to be able to establish a practice, and which it is not unheard of to charge $500/hr, it's not common either and not realistic for most people regardless of where you trained unless you're selling a particular brand of snake oil that convinces people to part with their cash.

it makes no sense to do both a C/L and neuropsych fellowship. one or other. neuropsych is a very academic fellowship so is unlikely to help with pp except if you are interested in forensics and could potentially have a successful forensic practice around civil neuropsych cases

Interesting. Again, I am just a PGY1 so I am learning and naive about a lot of this.

I was thinking of doing a Neuropsych fellowship because of my interest in mood disorders in patients who also have parkinson's, stroke, dementia, epilepsy, etc. As a result, I thought that by doing a fellowship would help me create a pp niche with this group of patients.

Or am I completely wrong about this?

 

[Armadillos]

This thread makes no sense to me , sounds like you want to be a high end PP psychiatrist and you think doing completely unrelated fellowships is the way to do that?

Probably would be more efficient to use the 125k+/year you loose by doing a fellowship to get swanky office decor, a really good web designer and getting in with whatever social scene the referring docs in your area are part of

 

[Blitz2006]

This thread makes no sense to me , sounds like you want to be a high end PP psychiatrist and you think doing completely unrelated fellowships is the way to do that?

Probably would be more efficient to use the 125k+/year you loose by doing a fellowship to get swanky office decor, a really good web designer and getting in with whatever social scene the referring docs in your area are part of

Well I do want a thriving PP, but as Leo Aquarius initially mentioned, I also want expert knowledge in these areas because of my personal interest in these 2 subspecialities of psych.

 

[DJspreadsheet]

it isn't just inpatient, outpatient c/l is the major growth area in the field especially with things like collaborative care and integrated care. some of the best c/l fellowships like UW and GWU have strong outpatient experience in things like psycho-oncology, transplantation, HIV etc. for pp one might be able to carve out a niche in caring for psychiatric problems in patients with specific medical problems, network with those specialists and get referrals etc

None of that training translates into a high-paying cash outpatient practice. And neither of those programs have layman name-cache to demand high-paying cash outpatients.

 

[MLT2MT2DO]

None of that training translates into a high-paying cash outpatient practice. And neither of those programs have layman name-cache to demand high-paying cash outpatients.

Additionally from what I have been able to gather, integrated care and collaborative care don't work outside of the academic setting as far as reimbursement is concerned.

 

[MacDonaldTriad]

If your goal is to get a swanky PP, you should do it the tried and true old fashion way. Get going on your own analysis and go for the PhD at your local psychoanalytic institute. You will find it very adequate in terms of spending time and money.

 

[OldPsychDoc]

This thread needs some simplification.

...Therefore, I was wondering if doing CL fellowship at a big name place would help my practice to 'flourish', for lack of better words?

No.
(For lack of a better word.)

 

[Shikima]

I'll let you in on a secret for building a 'flourishing' PP.

Step 1. Check your ego.
Step 2. Find an area that has good income/earnings and no competition.
Step 3. Build your name within the community as providing good work and developing relationships with the area PCP's.

 

[DJspreadsheet]

I'll let you in on a secret for building a 'flourishing' PP.

Step 1. Check your ego.
Step 2. Find an area that has good income/earnings and no competition.
Step 3. Build your name within the community as providing good work and developing relationships with the area PCP's.

re: Step 2 ... is there an advisable method for finding the magnitude of psychiatric competition in an area? Obviously Boston is inundated and Bismarck is not - it's the in-betweeners that I'm more curious about.

 

[Doctor Bagel]

re: Step 2 ... is there an advisable method for finding the magnitude of psychiatric competition in an area? Obviously Boston is inundated and Bismarck is not - it's the in-betweeners that I'm more curious about.

You talk to people in different communities. Probably be fairly easy to do by doing networking at APA, other national conferences. You could also look to see how many board certified psychiatrists are in each city and compare that with the population to find underserved areas. Maybe match this with income data looking for areas with high income/education and relatively low numbers of psychiatrists per capita. Talking to people, though, is probably the best tool because it's hard to figure out general attitudes in an area -- in east coast cities, paying out of pocket for long-term psychotherapy (including analysis) can be a normal things. It's pretty atypical in my west coast city and likely non-existent in the southwestern/midwestern area where I'm from.

 

[Doctor Bagel]

I'll let you in on a secret for building a 'flourishing' PP.

Step 1. Check your ego.
Step 2. Find an area that has good income/earnings and no competition.
Step 3. Build your name within the community as providing good work and developing relationships with the area PCP's.

Wouldn't building your ego also have some role by pushing you to advocate for your own worth in billing patients?

 

[dl2dp2]

re: Step 2 ... is there an advisable method for finding the magnitude of psychiatric competition in an area? Obviously Boston is inundated and Bismarck is not - it's the in-betweeners that I'm more curious about.

I would say as a rule, most places have a huge demand for insurance taking PP psychiatrist (even the most "saturated" places). Such a practice is tricky to set up though as a solo practice, and you may be better off working for a group (at least to start).

I work in one of the supposedly most saturated places. It's unclear why my PP is "flourishing" when people of comparable CV are not. A lot of this has to do with luck and marketing savvy, I think. I feel that the demand is very high, and I'm not always getting ultra wealthy patients either. In fact most of my patients are upper middle class.

 

[strangeglove]

One way a fellowship in CL or Neuropsychiatry at a "top program" would help in establishing a high-end PP would be in helping to secure a faculty position at said top program, which helps to justify charging patients high fees. Not that this is a good reason to be on the faculty (hopefully you also like to do research or teach).

 

[Asklepian]

Why fellowships in both C/L and Neuropsych? Would you expect to practice both?

 

[Shikima]

Wouldn't building your ego also have some role by pushing you to advocate for your own worth in billing patients?

A little humility will go a long way....

 

[Blitz2006]

Why fellowships in both C/L and Neuropsych? Would you expect to practice both?

Yep that's my plan. CL during the day (8 to 6) and then hopefully Neuropsychiatry pp in the evenings or wkds.

I'm just wondering how realistic this is.

 

[Blitz2006]

One way a fellowship in CL or Neuropsychiatry at a "top program" would help in establishing a high-end PP would be in helping to secure a faculty position at said top program, which helps to justify charging patients high fees. Not that this is a good reason to be on the faculty (hopefully you also like to do research or teach).

This is exactly my thinking of doing fellowship at top notch place. To help me get into a faculty position as a CL psychiatrist in a "top program", and then use the name brand to market myself in the pp.

I'm just wondering if my thinking translates to reality....

 

[Shikima]

This is exactly my thinking of doing fellowship at top notch place. To help me get into a faculty position as a CL psychiatrist in a "top program", and then use the name brand to market myself in the pp.

I'm just wondering if my thinking translates to reality....

Pedigree alone won't give you "credibility" these days.

 

[strangeglove]

This is exactly my thinking of doing fellowship at top notch place. To help me get into a faculty position as a CL psychiatrist in a "top program", and then use the name brand to market myself in the pp.

I'm just wondering if my thinking translates to reality....

It could, but nowadays if you are clinical faculty at any program they will tax your private practice or not even allow you to have one. So obtaining a faculty position to enable charging high PP fees is not a sound financial decision. Also, you will only have so much time to devote to PP if you are being productive enough academically to keep your faculty position. Then again, the fellowships for CL are only a year, and it will definitely add to your skills, if not your bottom line.

 

[Bartelby]

A few thoughts here from a PGY-III interested in private practice, maybe cash, maybe not. First, working 8-6 in a full time CL position and then working evenings and weekends at a PP sounds like a recipe for burnout, especially if you will have a family. For me that would be the nonstarter, though you may feel differently.

As for saying "I am Hopkins trained" my understanding of that is that it refers to your four year residency, though you could say something like "I trained at X along with a fellowship in psychosomatic medicine at Johns Hopkins" which sounds impressive. It may help get some people through the doors, though if you are looking at a cash practice (like I think you are) in an area in which that is common there will likely be plenty of people with impressive pedigrees to compete with. I think what will end up separating you from them is the quality of the service you provide. Thus, while you do need to think "how do I get people through the door," you need to think as much or more "how do I justify being worth the increased cost, and how do I provide such a stellar service that referring providers and patients keep sending new patients my way despite the increased cost?"

Looked at in that light I think that training which increases the quality of care in whatever niche you choose is key, more so than the branding of a major medical center. In addition publishing or other activities that brand you personally (rather than by association) as an expert could be helpful, especially for obtaining community referrals. You then need to think about what kind of practice you want to run. If you are interested in neuropsych, it is a fascinating subspecialty but I don't know how conducive it is to cash practice; I think people pay cash for things that they cannot easily get with insurance (long term therapy with a psychiatrist comes to mind). Since the population of cash-paying people with behavioral manifestations of neurological disease is smaller than, say, the population of people with anxiety disorders you may do better running a higher-volume practice that focuses on evaluation and overall management of patients (including medications, appropriate referrals, etc) which accepts insurance. Such a setup could be fulfilling and provide a great service, but I don't know about it being converted to cash-only.

Anyhow, these are all my own personal musings since I have never started a PP. Still, I think broadening your view to look at the many factors that will be more relevant to your practice/business than prestige is worthwhile. Also keeping in mind how much even the financial cost of two fellowships will be is important if you are considering this from a business angle.

 

[Blitz2006]

It could, but nowadays if you are clinical faculty at any program they will tax your private practice or not even allow you to have one. So obtaining a faculty position to enable charging high PP fees is not a sound financial decision. Also, you will only have so much time to devote to PP if you are being productive enough academically to keep your faculty position. Then again, the fellowships for CL are only a year, and it will definitely add to your skills, if not your bottom line.

Nice, Good to know. I didn't realize faculties will prevent you from having PP. So are these 'big shot' psychiatrists at Cornell/Columbia/Mt. Sinai hindered from having PP on the side?

 

[Blitz2006]

A few thoughts here from a PGY-III interested in private practice, maybe cash, maybe not. First, working 8-6 in a full time CL position and then working evenings and weekends at a PP sounds like a recipe for burnout, especially if you will have a family. For me that would be the nonstarter, though you may feel differently.

As for saying "I am Hopkins trained" my understanding of that is that it refers to your four year residency, though you could say something like "I trained at X along with a fellowship in psychosomatic medicine at Johns Hopkins" which sounds impressive. It may help get some people through the doors, though if you are looking at a cash practice (like I think you are) in an area in which that is common there will likely be plenty of people with impressive pedigrees to compete with. I think what will end up separating you from them is the quality of the service you provide. Thus, while you do need to think "how do I get people through the door," you need to think as much or more "how do I justify being worth the increased cost, and how do I provide such a stellar service that referring providers and patients keep sending new patients my way despite the increased cost?"

Looked at in that light I think that training which increases the quality of care in whatever niche you choose is key, more so than the branding of a major medical center. In addition publishing or other activities that brand you personally (rather than by association) as an expert could be helpful, especially for obtaining community referrals. You then need to think about what kind of practice you want to run. If you are interested in neuropsych, it is a fascinating subspecialty but I don't know how conducive it is to cash practice; I think people pay cash for things that they cannot easily get with insurance (long term therapy with a psychiatrist comes to mind). Since the population of cash-paying people with behavioral manifestations of neurological disease is smaller than, say, the population of people with anxiety disorders you may do better running a higher-volume practice that focuses on evaluation and overall management of patients (including medications, appropriate referrals, etc) which accepts insurance. Such a setup could be fulfilling and provide a great service, but I don't know about it being converted to cash-only.

Anyhow, these are all my own personal musings since I have never started a PP. Still, I think broadening your view to look at the many factors that will be more relevant to your practice/business than prestige is worthwhile. Also keeping in mind how much even the financial cost of two fellowships will be is important if you are considering this from a business angle.

Great post. exactly what I wanted to hear.

""how do I justify being worth the increased cost, and how do I provide such a stellar service that referring providers and patients keep sending new patients my way despite the increased cost?"

This is exactly my query. And this is why I feel I need to do a fellowship at a big name place, to 'justify being worth the increased cost'. Particularly since I am not doing residency at a big name presently.

Of course I agree that other factors are important (publishing, being personable, trustworthy, etc). But those are things that are in my control. Going to a big name fellowship will require a bit more work and diligence, correct?

I agree about neuropsych not being cash-inducive. I'm not looking at neuropsych as a cash cow. I simply find it to be a fascinating field, and I love neuroanatomy/neuroimaging. So patients with Dementia/Parkinson's/Stroke would just be a bonus in my PP. My secondayr interest is psychopharm/mood disorders, which I presume will be the brunt of my PP population.

So I am definitely going to a neuropsych fellowship (for personal interest). I'm on the fence about CL fellowship. I would like to do CL in the weekdays, but am not sure how worthwhile the fellowship. Essentially if I do it, it will be to "justify....". Sure an extra year of CL training will strengthen my psych skills, but is it worth burning another year?

 

[Blitz2006]

Pedigree alone won't give you "credibility" these days.

Of course not. But in this cutthroat market, everything helps...no? (Particularly LA/NYC market)

 

[Dharma]

Yep that's my plan. CL during the day (8 to 6) and then hopefully Neuropsychiatry pp in the evenings or wkds.

I'm just wondering how realistic this is.

Superman ish there!

 

[Bartelby]

A good starting point would be telling us what you want your private practice to look like, day to day. Are you planning on seeing VIP mood disordered patients for weekly or more frequent hour-long psychotherapy visits? Doing medication checks for complex patients at the interface of neurology and psychiatry and branding yourself as a treatment-resistant affective disorders specialist? Providing consultation to community hospitals or nursing homes? Also how would any of this fit with a full-time academic appointment, especially if they impose limitations on the scope of duties outside of your academic appointment? More clarification on this could be useful, specifically what a typical day would 'break down' to ideally for you (for instance, seeing 4-5 hour long cash integrated psychotherapy cases in the morning, then going to a insurance-based group practice neuropsychiatric clinic for 20-30 minute medication checks for 4-5 hours in the afternoon).

Also consider that a psychosomatic year will bring a salary of approx $70k, whereas a year of attending salary (if you are not in academics) is likely near $200k, or more if you hustle as hard as you seem to want to. Taking the $130k pre-tax difference will likely land you somewhere close to $100k post-tax difference in addition to giving you a one year "head start" in your private practice. As you get closer to fellowship time you will be able to clarify for yourself how helpful either given path would be, but for me personally it would be an either/or proposition for neuropsych and CL.

 

[manly_man246]

I've seen the $200k number thrown around a lot for Psych attendings, is that starting? I can't imagine you'd still be making that 5 years into your practice even, no? (I get that per hour it's quite good) Anyhow I'm also considering C-L but the fact that more and more institutions are restricting your ability to moonlight or see PP on the side is making it less appealing, but I feel I'd get tired with a typical PP setup.

 

[peppy]

I've seen the $200k number thrown around a lot for Psych attendings, is that starting? I can't imagine you'd still be making that 5 years into your practice even, no? (I get that per hour it's quite good) Anyhow I'm also considering C-L but the fact that more and more institutions are restricting your ability to moonlight or see PP on the side is making it less appealing because FT CL-only wouldn't put me where I'd like to be financially pre-tax, but I feel I'd get tired with a typical PP setup.

I just recently finished my job search in the midwest. Where I live, 200K would be a very high starting figure for ACADEMIC psychiatry, but it would be a pittance for a general psychiatrist working for a non-academic hospital in the community. Yes, even as a brand new grad, you can find jobs that pay substantially more than 200K outside of the academic world. The same may not be true on the coasts, but you sure as hell can rake it in if you are willing to live in flyover land. And, no, I don't live in a rural area. I focused my search on a major city in the midwest.

If you do end up taking a job as a CL psychiatrist, I suggest making sure that you only do it on SALARY, since a lot of the time consuming stuff you do in CL doesn't translate well to billing for your time (for example, you might spend a lot of time talking to patient families, to other docs, and to nurses). On salary, you can definitely make >200K doing at least some of your time in C/L work but my experience has been that it is rare to find a position that is 100% CL. Most places will expect you to see some outpatients or round on the inpatient psych unit, too, not just spend all your time waiting for consults to come in.

 

[peppy]

The main situations that I could see a psychosomatic medicine fellowship being useful for outpatient work would be if you wanted to develop a niche seeing a certain population of medically complex psych patients AND already had a ready source of referrals from that patient base. For example, there are some hospital organizations that now have "Women's Mental Health" programs, and doing a Psychosomatic fellowship where you had a lot of experience treating preggos with psychiatric issues (for example) would be helpful in having a basis for declaring yourself an expert in women's mental health issues so that the ob/gyn service would call you whenever they had a preggo with a psychiatric problem. I think it is definitely possible that if you are fellowship trained and have experience seeing outpatient psych patients who have cancer, an organ transplant, heart disease, etc. that you could work for a large hospital and request that they help you set up your outpatient time as the go-to guy/gal for any psychiatric referrals coming from the cardiologist, the oncologist, the transplant team, or whatever.

However, I don't think there would be enough people looking for a private practice psychiatrist with that kind of sub specialized expertise that it would make sense to do the the CL fellowship for the sake of impressing cash-paying patients in private practice. The average person doesn't even know what psychosomatic medicine IS, let alone what universities are actually the best places to train in it.

The reality is that the shortage of psychiatrists is so severe that you don't NEED to bend over backwards trying to make yourself stand out to make a lot of money and have plenty of work.

I think it only makes sense to do a psych fellowship if you have a sincere interest in the topic. It's really more of a waste of time if your main concern is to try to maximize your profit and marketability.

I also suggest asking some hospital recruiters in the area where you are considering working about how practical it would be to design a job like what you have in mind within their organization. That might help you judge how realistic your dream set up is.

 

[675015]

This is exactly my thinking of doing fellowship at top notch place. To help me get into a faculty position as a CL psychiatrist in a "top program", and then use the name brand to market myself in the pp.

I'm just wondering if my thinking translates to reality....

So you want to have a full time job at a top program just so you can have a high paying clientele for a few hours a week?

 

[Blitz2006]

The main situations that I could see a psychosomatic medicine fellowship being useful for outpatient work would be if you wanted to develop a niche seeing a certain population of medically complex psych patients AND already had a ready source of referrals from that patient base. For example, there are some hospital organizations that now have "Women's Mental Health" programs, and doing a Psychosomatic fellowship where you had a lot of experience treating preggos with psychiatric issues (for example) would be helpful in having a basis for declaring yourself an expert in women's mental health issues so that the ob/gyn service would call you whenever they had a preggo with a psychiatric problem. I think it is definitely possible that if you are fellowship trained and have experience seeing outpatient psych patients who have cancer, an organ transplant, heart disease, etc. that you could work for a large hospital and request that they help you set up your outpatient time as the go-to guy/gal for any psychiatric referrals coming from the cardiologist, the oncologist, the transplant team, or whatever.

However, I don't think there would be enough people looking for a private practice psychiatrist with that kind of sub specialized expertise that it would make sense to do the the CL fellowship for the sake of impressing cash-paying patients in private practice. The average person doesn't even know what psychosomatic medicine IS, let alone what universities are actually the best places to train in it.

The reality is that the shortage of psychiatrists is so severe that you don't NEED to bend over backwards trying to make yourself stand out to make a lot of money and have plenty of work.

I think it only makes sense to do a psych fellowship if you have a sincere interest in the topic. It's really more of a waste of time if your main concern is to try to maximize your profit and marketability.

I also suggest asking some hospital recruiters in the area where you are considering working about how practical it would be to design a job like what you have in mind within their organization. That might help you judge how realistic your dream set up is.

I agree 100%. Like I said earlier, I am doing Neuropsych due to my sincere interest. CL fellowship I'm on the fence. But I enjoy working with other specialities, which is why I want to do CL, and the thought of being able to have outpatient CL time with psych referrals from oncologists, etc., is very appealing. So like a broken record in this thread, just gotta figure out if the CL fellowship is beneficial. What you describe is my ideal scenario. Question is, do I need fellowship to get referrals from oncologists and cardiologists? I'm not sure.

 

[VMSmith]

If your plan is to build a cash only private practice charging $300-400 per psychotherapy hour, then doing a CL fellowship is probably not worth the year of severely restricted income.

Having analytic training will help you build the kind of professional network that gets you referrals for those 2-5 times per week cash only patients for therapy. Doing an addictions fellowship in NYC can do a similar thing, for scions of I-bankers who are addicted to pot or painkillers and need buprenorphine or whatever. Having a CL fellowship, even from a name-brand institution, won't really do that much for you. The patients who are paying several hundred dollars out of pocket are not necessarily medically ill, and you don't need CL training to take care of them - especially since the treatment that you get to charge so much for is not medical complexity related.

 

[VMSmith]

If your goal is to work full time as a CL attending at an academic center, then yes by all means do a CL fellowship. You can do a PP on the side, this is a pretty common practice for CL attendings in NYC. But the reason those psychiatrists practices are successful is not because they have CL training, it is because they have professional networks in NYC for referrals, and generally are either analytically trained or did residencies at programs with strong psychoanalytic traditions.

Edit to add bc I think this is what your thinking is: yes, if you do a CL fellowship and get hired at one of the elite institutions in NYC, this will help you develop a professional reputation within that institution that could someday lead to more referrals for you. But this plan depends on a lot of factors outside your control, and if your goal is to build a successful cash based PP is far from the best route.

 

[hamlake]

This is not quite in line with how the thread has evolved, but I'm wondering which C-L fellowships have a larger focus on elective time and outpatient C-L rather than the traditional inpatient consults? I am considering C-L fellowship in the future and I like inpatient consults but outpatient C-L is the most interesting to me. I don't have 1st hand experience on how various C-L fellowships are organized, but some of the C-L fellowship's curricula that appeal most to me are Michigan's (http://www.psych.med.umich.edu/education/psychosomatic/rotation.asp) and Penn's (https://www.med.upenn.edu/psych/psm_fellowship.html) because both seem to have a larger focus on elective time and/or outpatient C-L in various subspecialty clinics based on their websites.

 

[hamlake]

penn is not really known for psychosomatics. the link you posted doesn't mention any elective time. it would be pretty unusual for there to be elective time beyond an academic half day in a 1 year fellowship like this. but it does look like they have a broad range of experiences. as i mentioned previously probably two of the best ones that have significant outpatient exposure built in are GWU which has one of the oldest and most highly regarded and UW which is best known for outpatient consultation, including integrated care and the collaborative care model and you would get trained in all of these. the michigan one looks interesting in that there is geriatrics and addiction requirements which would be atypical for a psychosomatic fellowship. i dont know anything about it, again its not known for psychosomatics and while i can see how geriatrics and addictions are of course relevant to psychosomatics, i do find it odd that they have this in the fellowship which makes me a bit suspicious.

the one thing to bear in mind about outpatient consultation is since most of your patients will be new intakes you will have a ton of notes to write and no time built in, especially as patients may be complex (in fairness some are extremely straightforward). so it can get quite painful. outpatient consult notes are the bane of my existence.

Thanks. I guess what I'm looking for (if it exists) is a fellowship program that dedicates 30-50% of the time to outpatient C-L which is why I find Michigan's rotation schedule attractive, though I can't really attest to the quality of the experiences there. Penn's website doesn't really say how much time is allotted for all of those subspecialty clinics, but I like the idea of broad exposure to all of those subspecialty clinics. I am somewhat familiar with GWU's fellowship and they only really do 2-ish half-days per week of outpatient C-L, and from what I know, the HIV psychiatry experience is probably the most robust outpatient experience while the other outpatient experiences are less so. UW's program has 2 half-days per week of outpatient C-L per their website (http://depts.washington.edu/psychcl/rotations.html )--I would prefer at least 3 half-days per week, but 2 half-days is not bad. I am interested in both psycho-oncology and collaborative care which are listed in UW's example schedule. Do you know if there are other robust outpatient C-L experiences that UW offers, e.g. HIV psychiatry, Pain, Neurology, GI, Women's Health? It would great to do one-half day per week, 6 months each, of 4 different C-L clinics throughout fellowship. MGH (http://www.massgeneral.org/psychiatry/services/psych_med_services.aspx) has a pretty big C-L department with staff psychiatrists assigned to various subspecialty clinics/services, though I wonder how their fellowship is setup in terms of how much time is dedicated to outpatient C-L.

 

[hamlake]

the penn website says 4.5 months full time.
MGH used to be a ton of inpatient consults and not much of anything else. not sure if that has changed you should just ask greg fricchione or ted stern. they certainly have one of the most established and prestigious consult fellowships
UW has a range of outpatient consultation clinics (HIV, maternal infant care, regional heart center, psycho-oncology, pain, diabetes etc and then in the primary care clinics they have BHIP where you only see patients the care manager wants you to see and consult by phone or in person with the care manager for recommendations on all the other patients. they also have the MHIP or collaborative care program providing consultation to the rest of the state and i think wyoming). Im not sure what the fellows rotate at now, but they used to do HIV, psycho-oncology, diabetes, pain, adult medicine, and MHIP I think. I think there might be VA outpatient consultation stuff as well but not sure. I am not sure if how much choice you get because there are a number of different consultation clinics. I think they do more outpatient stuff when based at UW (?3 half-days) vs the other sites where its just 2 half-days a week.

consultation liaison psychiatry is mainly an inpatient based specialty so i think you will be unlikely to find one that is so heavy on outpatients. Outpatient consultation is really quite different, and there is often a mismatch between referring provider and consultant expectations (i.e. you will take over the management over the patient vs. you will provide recommendations on management and in many places there isn't the same liaison component because people are often in their own worlds in an outpatient setting. If you are mainly interested in outpatient then it may not even be that helpful to do a psychosomatic fellowship unless outpatient consultation is something you don't get experience in.

depending on your program you could just do a ton of outpatient consultation stuff in your 4th year and maybe even set up a clinic. i am setting up a neuropsych consultation service for example. there is almost certainly a need. you just have to make sure the specialty clinic will give you a room and understands that consultation means you will provide an opinion and send them back to the referrer.

Okay, I was interested enough to e-mail MGH about their schedule. In addition to inpatient consults through the whole year, it looks like fellows do 2-hours per week in the primary care clinic for the whole year, 2 hours per week in Infectious Disease clinic for part of the year (not sure for how many months), and 2 hours per week of Oncology clinic for part of the year (not sure for how many months).

I also got a recent schedule for fellows at Penn. For 4.5 months, fellows rotate in 7 different specialty clinics (Neurology, Oncology, Anesthesia/Pain, Transplant, Ob/Gyn, HIV, Gastroenterology) for 1/2 day each per week plus 1/2 day per week in Med/Psych clinic and 1 day per week of inpatient consults or research time. For the other 7.5 months, time is split in blocks between the university hospital and the VA doing inpatient consults. When at the VA, there is involvement in ambulatory clinic and palliative care. When at the university hospital, I believe there is a weekly 1/2 day Med/Psych clinic. This schedule is based on 3 fellows, however, when they usually only have 2 fellows.

 

[VMSmith]

What interests you about outpatient CL?

Collaborative/Integrated Care the trend for doing outpatient CL work, and APM is trying to position the subspecialty as THE subspecialty for collaborative care. It's not really traditional CL psychiatry, which is inpatient-based, and in general CL fellowships still don't give you any training in the model (despite the focus of APM on the model). Right now, CL training remains mostly inpatient medicine based. Doing a 3-4 month block seeing outpatient consults in one clinic or another doesn't let you integrate much into any given clinic (with just 2 hrs a week at a clinic, it'll probably take you 2 months just to learn who everyone is), so the focus of your experience will probably just be learning to care for the psychiatric needs of medically ill patients, just like it would be if you spent that time on the inpatient setting.

If doing outpatient work is what you see for yourself (as opposed to traditional CL psychiatry) then I would strongly suggest you look at UW more closely, even if the ratio of outpatient to inpatient CL work during the fellowship year doesn't match up with what you're hoping for. What you have there is the opportunity to learn how to implement a different model of care, which is a skillset on top of the general CL skillset, and if you're looking into an academic or administrative career can be very valuable.

 

[hamlake]

What interests you about outpatient CL?

Collaborative/Integrated Care the trend for doing outpatient CL work, and APM is trying to position the subspecialty as THE subspecialty for collaborative care. It's not really traditional CL psychiatry, which is inpatient-based, and in general CL fellowships still don't give you any training in the model (despite the focus of APM on the model). Right now, CL training remains mostly inpatient medicine based. Doing a 3-4 month block seeing outpatient consults in one clinic or another doesn't let you integrate much into any given clinic (with just 2 hrs a week at a clinic, it'll probably take you 2 months just to learn who everyone is), so the focus of your experience will probably just be learning to care for the psychiatric needs of medically ill patients, just like it would be if you spent that time on the inpatient setting.

If doing outpatient work is what you see for yourself (as opposed to traditional CL psychiatry) then I would strongly suggest you look at UW more closely, even if the ratio of outpatient to inpatient CL work during the fellowship year doesn't match up with what you're hoping for. What you have there is the opportunity to learn how to implement a different model of care, which is a skillset on top of the general CL skillset, and if you're looking into an academic or administrative career can be very valuable.

That is a very good point that UW may be the only place where collaborative/integrated care as a model is robustly implemented and taught. I like both inpatient and outpatient C-L, and my ideal practice would be a combination of the two. I like the longitudinal care and patient-doctor relationship of outpatient C-L (if not conducted in a purely consultative role) that doesn't really exist with inpatient C-L. To me, being the go-to embedded psychiatrist for an HIV, Oncology, or Women's Health/OBGYN clinic, would be a cool job.