Big raise feel nothing

[Attending1985]

I was given a 30k raise today in my base salary. I’m employed by one of two big hospital systems in my area. They’ve treated me well.

What surprised me is I really didn’t care about the raise.

I’ve been wanting to practice with full autonomy for quite some time. I want to do therapy with the majority of my patients. Right now, it’s the minority.

When I was told about my raise I was also told about a push for more access. This means pushing to see patients for short intervals then transfer them back to primary care. I really value long term relationships with patients. I don’t want to be seeing new patients constantly it’s too stressful.

I’ve been here for 6 years and the raise I’m sure is to promote retention. It’s nice to feel more valued but I really thought it would make a bigger impact on me.

I still want to leave and feel blah about the raise.

Anyone relate?

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[ObsequiousAplomb]

I can definitely relate. My struggle would be avoiding the guilt of leaving after finally getting a raise prevent me from leaving if that's what I really wanted to do.

This is what sucks the most about finally getting a raise when it still feels too little, too late.

 

[Candidate2017]

I’ve been wanting to practice with full autonomy for quite some time. I want to do therapy with the majority of my patients. Right now, it’s the minority.

When I was told about my raise I was also told about a push for more access. This means pushing to see patients for short intervals then transfer them back to primary care. I really value long term relationships with patients. I don’t want to be seeing new patients constantly it’s too stressful.

If you work for a large clinic or organization, your job is to take all comers off the street who can afford you, take them into your room, and service them. Every 15, 20, or 30 minutes, another one off the street and into your room. All day. Then you hand over a portion of your earnings to someone else, which is the real point of this enterprise. After while, it's totally normal to feel nothing.

At the end of the day, no one cares about what you want. If you want out of The Life, it's up to you because there's certainly no task force to swoop in on your employer and save you.

 

[splik]

I got a 40k raise a few months ago. It was a pay cut in disguise. I quit.

As an aside, one of my colleagues commented that whenever you get a big pay rise, it tells you how much you've been underpaid and how much you are still being underpaid.

 

[Sushirolls]

Time to open your own practice.

 

[reca]

I got a 40k raise a few months ago. It was a pay cut in disguise. I quit.

As an aside, one of my colleagues commented that whenever you get a big pay rise, it tells you how much you've been underpaid and how much you are still being underpaid.

Whoa, so are you still in academia or out in private practice now?

 

[G Sheb]

30K is meh.
Get out if you don't like it.

 

[TheRightMedication]

I took a pay cut to not work weekends and make more time for a private practice.

Feels good.

 

[Bartelby]

Inflation is almost 10 percent. If you make an average $250k or so, then this is slightly over what amounts to a cost of living increase. Combined with being told that your job is getting worse in the name of access, it's a bit of a wash. In fairness, many employers will leap on this opportunity to in effect decrease wages year after year, so beating inflation is impressive.

I don't know about you, but I care more about working conditions than pay (as long as the pay is good enough). I would rather work at a pace I enjoy providing the quality of care I am comfortable with than make outsized money with bad working conditions. Whenever I hear my employer has unilaterally decided to add workload / make my job more stressful and less fulfilling, it's rage-inducing (even if they throw a small raise my way at the same time).

 

[TexasPhysician]

At some point it is time to decide if you want to maximize money, work fulfillment, or work-life balance. You can’t maximize them all simultaneously. Most people get 1 of those. Some 0 and some 2.

Once you are making $200-400k, does another $50k make a big difference to you?

Either through a small group practice or starting on your own, you’ll likely achieve more of what you want.

 

[AcronymAllergy]

Sounds like you aren't particularly happy with the job. If you haven't already and PP is an option, you could just set aside that entire raise and then some for some savings and (if going it on your own) start-up costs, and then jump ship to solo/group practice. Then you can do as much therapy as you want. I don't think you'll ever have full autonomy working for someone else, which is the trade-off for the general security that comes with an employed position.

Also, yes--more money, especially if you didn't have a defined goal for it, doesn't always have much of an emotional impact after a certain point. Especially if you already don't like what you're doing.

Edit: And second everything TexasPhysician just said above. Us psychologists also usually add "good location" to the list of things we want, but psychiatrists don't always have that same problem.

 

[annoyedpsychiatrist]

I also got a raise recently in that ballpark. For me actually, for how many wrvus im generating (i havent been at this job long, building a caseload) my base salary is highly competitive. I do get 30 minute follow ups with my patient but there is a push that after being stable for 6+ months we send back to PCPs (besides the schizo/bipolar patients/severe patients). At first I didn't like that idea, but the reality is a lot of people need help and before I got here, people were waiting 6+ months for new patient apts. If someone has been stable for a year on zoloft 50mg do they really need to keep seeing us? Tbh I hated my last job, and by comparison my new job is 100x better. If you arent happy with where you're at life is too short to not at least try and find the happiness you desire.

Correct me if im wrong, but how I read that is that your patient load isnt necessarily increasing (as far as shorter patient visits/higher number of patients) you're just being encouraged more to discharge stable patients and take more new ones? If theyre shortening visit times and adding pts on top of that then that would be concerning.

Really theres pros and cons to each setting. In my experience most of the standard private practice type jobs were about seeing as many people as possible for zoloft refills. Obviously not all, but quite a few. One place i interviewed at nearly two years ago, they were seeing 30 pt a day

 

[Attending1985]

At some point it is time to decide if you want to maximize money, work fulfillment, or work-life balance. You can’t maximize them all simultaneously. Most people get 1 of those. Some 0 and some 2.

Once you are making $200-400k, does another $50k make a big difference to you?

Either through a small group practice or starting on your own, you’ll likely achieve more of what you want.

Right now my work life balance and money are maximized. For me, it’s hard to give that up and start a pp knowing I would be more fulfilled but would the things I have right now be lostz? Would I regret that at this stage of my life with small children?

 

[smalltownpsych]

The bad thing about pressure to hand off patients to primary care is that you could get stuck with the less motivated and more frustrating patients aka less rewarding. I prefer having more control over this process as it doesn’t always correlate with severity of clinical presentation or symptoms. As the clincian, I can determine what makes sense for me and my patient and I really don’t want someone else involved. Therefore, private practice 😁

 

[Monocles]

You guys are getting raises??

 

[TheRightMedication]

Right now my work life balance and money are maximized. For me, it’s hard to give that up and start a pp knowing I would be more fulfilled but would the things I have right now be lostz? Would I regret that at this stage of my life with small children?

I'm not sure why you'd give that up! Sounds ideal to me.

 

[BACyeahyouknowme]

The “increased access” thing is 100% an MBA-driven scam, imo. This is a race to the bottom. We can’t see everybody, but we can and should endeavor to provide the best-quality care to the patients we have accepted into our practice.

The idea that I pick the right collection of pills and ship someone back to their PCP is frankly offensive. It suggests a naive approach to psychiatry and devalues the progressive nature of a quality treatment.

Meanwhile, you’re shipping every stable patient back to their PCP, so what do you get? Well, lots more unstable new evals. More work, more liability, more time spent in chart review. Never really getting to understand the patient. Never getting to offer them improvement beyond “basically stable” on whatever the med regimen is. That sounds like urgent care or something, not longitudinal, quality psychiatric care.

So I am highly suspicious that these drives towards increased “access” really mean worse care for more people. Sorry, but I didn’t train this hard to deliver low-quality care so some suit can brag about increasing access to his cronies.

Sorry about the rant, but I’ve been involved in situations like this (CMH settings), and the push for more patients in shorter slots was detrimental to quality of care and staff morale.

 

[annoyedpsychiatrist]

Meanwhile, you’re shipping every stable patient back to their PCP, so what do you get? Well, lots more unstable new evals. More work, more liability, more time spent in chart review. Never really getting to understand the patient. Never getting to offer them improvement beyond “basically stable” on whatever the med regimen is. That sounds like urgent care or something, not longitudinal, quality psychiatric care.

I get what youre saying as it does increase the amount of more challenging patients that you get and i originally saw it as that, but if a low acuity pt has been doing fine for several months and you're seeing them like every 6 months, do they really need your services?

From a patient perspective, there are people waiting several months just to see a psychiatrist, this is definitely a thing in many areas. Im totally in agreeance with wanting good/motivated patients, 100%. But if we dont discharge people ever and continually see the same stable people over and over, there are peole who need help who wont be able to get in. There is def a prominent shortage of psychiatrist. Does it suck taking on more patients due to increased risk? Yeah definitely increased risk of burnout for sure. But I dunno, i have mixed feelings on this. I did go into this career with the goal of wanting to help people the best I could and at certain point its not therapuetic because they have graduated, so to speak.

 

[BACyeahyouknowme]

I get what youre saying as it does increase the amount of more challenging patients that you get and i originally saw it as that, but if a low acuity pt has been doing fine for several months and you're seeing them like every 6 months, do they really need your services?

From a patient perspective, there are people waiting several months just to see a psychiatrist, this is definitely a thing in many areas. Im totally in agreeance with wanting good/motivated patients, 100%. But if we dont discharge people ever and continually see the same stable people over and over, there are peole who need help who wont be able to get in. There is def a prominent shortage of psychiatrist. Does it suck taking on more patients due to increased risk? Yeah definitely increased risk of burnout for sure. But I dunno, i have mixed feelings on this. I did go into this career with the goal of wanting to help people the best I could and at certain point its not therapuetic because they have graduated, so to speak.

Absolutely, I can see that perspective. I’m a few years out, so maybe our colleagues with more experience can weigh in on this, too, but…I actually do think there’s value in hanging on to people. Earlier in my training, I didn’t realize how many levels there are to psychiatric recovery. It’s not just “stable or not,” but it’s a long gradient from non-functional to someone who is living their best life. I think I have value at every step of that process, as the patient hopefully keeps improving. Maybe I’m being a little optimistic!

 

[SubzDoc]

Absolutely, I can see that perspective. I’m a few years out, so maybe our colleagues with more experience can weigh in on this, too, but…I actually do think there’s value in hanging on to people. Earlier in my training, I didn’t realize how many levels there are to psychiatric recovery. It’s not just “stable or not,” but it’s a long gradient from non-functional to someone who is living their best life. I think I have value at every step of that process, as the patient hopefully keeps improving. Maybe I’m being a little optimistic!

I've discussed this with colleagues before. After I got to the point where my outpatient clinic was busy with unstable patients, I started developing ways of hanging on to some regular, routine, stable cases to slow the day down. But eventually I started seeing these in a different light, I would question why I was seeing some of these pts. It was stressful in a different way, making me feel ineffective. Balance is good, feeling effective is good. Some of us can feel effective with a panel of stable, happy, long-term patients, some of us can't. I don't think reducing the length of appointments and increasing panel size makes people feel more effective.

 

[annoyedpsychiatrist]

I've discussed this with colleagues before. After I got to the point where my outpatient clinic was busy with unstable patients, I started developing ways of hanging on to some regular, routine, stable cases to slow the day down. But eventually I started seeing these in a different light, I would question why I was seeing some of these pts. It was stressful in a different way, making me feel ineffective. Balance is good, feeling effective is good. Some of us can feel effective with a panel of stable, happy, long-term patients, some of us can't. I don't think reducing the length of appointments and increasing panel size makes people feel more effective.

i agree that reducing apt length is never effective, if anything I wish we had more time with some patients.

But yeah, agree with both of you guys, almost like a double edged sword. You want to hang on to good, compliant patients you like. Some patients just drain the hell out of you, and a full panel of that, i dunno how someone wouldnt become a psych patient. Yesterday I randomly had a day like that where it was all benzo/perosnality disorder patients and having a patient telling me im a bad person for not giving them adderall IR and xanax is far from enjoyable. But Its also nice sometimes really make a difference in someone's life when they had pretty much no hope before they saw you. Psychiatry has days where you feel like the hero, and other days where you question if you're making a difference. At least for me thats the cas.e

 

[calvnandhobbs68]

The idea that I pick the right collection of pills and ship someone back to their PCP is frankly offensive. It suggests a naive approach to psychiatry and devalues the progressive nature of a quality treatment.

I think this is the real issue here.

It's also being semi-mindless about what we're doing with medications cause you know what happens when they go back to their PCP? The PCP just keeps refiling it indefinitely and if there's ever any questions about going up or down on the medications, they send them back to psychiatry. I'm also often very mindful about having discussions about discontinuing medications (especially when seeing kids)....if someone's been stable for 9-12 months, it's actually guidelines for most depressive and anxiety disorders that you discuss trialing off the medications. However, you don't get to that discussion unless you've been seeing someone who's been stable for 9-12 months.

Are there people I send back to their PCP? Absolutely, especially if it's clearly a burden to come see me and they'd be totally fine with annual refills through their PCP.

 

[comp1]

Second the inflation issue. Your salary is net neutral. Why would you get excited? I think it's good that your company at least recognizes the need to do this both for inflation and if they have some new metric they have to adhere to coming down from on high.

 

[Candidate2017]

You guys are getting raises??

You didn't get the memo? That's ok. Just ask for more money.

 

[splik]

Whoa, so are you still in academia or out in private practice now?

I left academia for private practice.

 

[annoyedpsychiatrist]

I will say the tax burden kind of sucks for doctors, especially if you're not married. Once you realize how much a raise really is after taxes it is mildly depressing at times, but oh well a raise is still a raise. My last job would not have done this. Also if they're offering you more money they must at least want to keep you, so to me thats a sign of a good faith

 

[WisNeuro]

I will say the tax burden kind of sucks for doctors, especially if you're not married. Once you realize how much a raise really is after taxes it is mildly depressing at times, but oh well a raise is still a raise. My last job would not have done this. Also if they're offering you more money they must at least want to keep you, so to me thats a sign of a good faith

Just go private practice and take advantage of the many ways in which you can shelter money from taxes.

 

[annoyedpsychiatrist]

Just go private practice and take advantage of the many ways in which you can shelter money from taxes.

I have 4.5 years left of PLSF though so for me can be a gamechanger

 

[WisNeuro]

I have 4.5 years left of PLSF though so for me can be a gamechanger

Fair, just be setting stuff up for once that day hits, then.

 

[mistafab]

At some point it is time to decide if you want to maximize money, work fulfillment, or work-life balance. You can’t maximize them all simultaneously. Most people get 1 of those. Some 0 and some 2.

Once you are making $200-400k, does another $50k make a big difference to you?

Either through a small group practice or starting on your own, you’ll likely achieve more of what you want.

Once again, @TexasPhysician drops absolute golden pearls in the psych forum. Learned so much from you.

As an aside, we negotiated with our hospital and got a 50% increase in moonlighting pay. Motivation from this forum helped me do these negotiations. Feels great.

 

[Attending1985]

The “increased access” thing is 100% an MBA-driven scam, imo. This is a race to the bottom. We can’t see everybody, but we can and should endeavor to provide the best-quality care to the patients we have accepted into our practice.

The idea that I pick the right collection of pills and ship someone back to their PCP is frankly offensive. It suggests a naive approach to psychiatry and devalues the progressive nature of a quality treatment.

Meanwhile, you’re shipping every stable patient back to their PCP, so what do you get? Well, lots more unstable new evals. More work, more liability, more time spent in chart review. Never really getting to understand the patient. Never getting to offer them improvement beyond “basically stable” on whatever the med regimen is. That sounds like urgent care or something, not longitudinal, quality psychiatric care.

So I am highly suspicious that these drives towards increased “access” really mean worse care for more people. Sorry, but I didn’t train this hard to deliver low-quality care so some suit can brag about increasing access to his cronies.

Sorry about the rant, but I’ve been involved in situations like this (CMH settings), and the push for more patients in shorter slots was detrimental to quality of care and staff morale.

This is exactly how I feel. You stated it perfectly, There is no respect for the value, quality or complexity of my work from above. Combined with this insane notion that I can see everybody with a different workflow.

 

[Stagg737]

Right now my work life balance and money are maximized. For me, it’s hard to give that up and start a pp knowing I would be more fulfilled but would the things I have right now be lostz? Would I regret that at this stage of my life with small children?

Early career that seems like a good place to be. High earnings put into investment make more money in the long run than money earned later, and time with your kids when they're young is time you'll never get back. Not saying you should stay at a job you hate, but if what you need to feel fulfilled is PP and you know it'll take years to build the one you want then at this point it's probably worth it in the long run to stick stick out tolerable jobs, make that money, and enjoy the time with your kids while it's there.

 

[FlowRate]

Right now my work life balance and money are maximized. For me, it’s hard to give that up and start a pp knowing I would be more fulfilled but would the things I have right now be lostz? Would I regret that at this stage of my life with small children?

Any potential with your current employer to drop hours to test out private practice? At mine, you can drop to 0.5 FTE and become part time which means no benefits but allows you to do outside work which at least gives some stable salary while you make that transition.

I'm in a similar spot where I think the thing most lacking in my current job is intangible/fulfillment. I don't think I'm likely to come across any employed position that's better and private practice outcomes are never a guarantee, so I'll likely stay for a while.

 

[Sushirolls]

I took plunge into PP, with student loan debt, very young kids.
Money isn't the only part of equation.

Upcoming parent teacher conferences. I looked at my schedule, made the changes in less than a minute. I'll be there. Priceless having that control without going through levels of admin for time off. Hunting seasons come along, I got the time off. Friend needs help last minute to pack an Elk miles out of the woods, I'm there.

 

[TheRightMedication]

I hadn't thought about the need to dress and transport game as a reason for private practice but by George you're right.