Creation of paid externship

[clinton]

I have felt some movement towards equitable labor practices in the US (long way to go yet) and was reflecting on what it felt like to provide free services for years during training. I have been privileged enough to establish a solo private practice and have had some contact with training directors as I embark on creating an externship. I’ve received the message that “training cannot occur at a place of employment” when attempting to offer pay.

Would anyone be willing to donate their time (I know, I know) to see if their student handbook has language like this that prevents ‘employment?’ I am hopeful of finding a way to offer compensation while abiding by this language.

It has long sense been time to pay students for their work. Hospitals bill insurance, counseling centers facilitate retention, and so on. Our field talks of ‘learning your value’ only to not offer pay for services delivered in the early years, then underpay interns and post-docs.

Thank you to anyone who is available to assist, and I wish you all well in next steps.

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[PsyDr]

If you’re billing for student services, you need to contact an attorney

 

[psycle708]

My program's handbook has a stipulation that students cannot have "outside employment" without approval (meaning outside of our fellowship which is TA/RA duties). I'm not aware of any practicum sites in my area that pay, but when I was applying at other schools, there was at least one that said there were paid practicum opportunities (the exception not the rule, I'm sure). The one that I remember for sure was UT Austin's school psych program, if you're interested. Can't be sure about the others.

 

[clinton]

If you’re billing for student services, you need to contact an attorney

Can you clarify what you mean by this?

For some context, I have not yet offered this experience to any student or training program and am attempting to understand barriers to paying externs. Further, certain insurance companies in certain states allow billing for Master's level individuals who are receiving supervision from a licensed psychologist who is credentialed with that insurance.

Vaguely gesturing to legality in this way seems to be an attempt to paint extern compensation as some sort of ethical issue, and it does not appear to be keeping with the spirit of this forum.

 

[clinton]

My program's handbook has a stipulation that students cannot have "outside employment" without approval (meaning outside of our fellowship which is TA/RA duties). I'm not aware of any practicum sites in my area that pay, but when I was applying at other schools, there was at least one that said there were paid practicum opportunities (the exception not the rule, I'm sure). The one that I remember for sure was UT Austin's school psych program, if you're interested. Can't be sure about the others.

Thank you for your response, and for the reference to a training community that did have paid opportunities. I am looking into the language used in handbooks and 'no outside employment without approval' is certainly a theme. I take some issue with the notion because a student providing services at a externship as a contractor not employee (1099 rather than W2 in IRS language) would be under the same level of 'control/direction' from the supervising psychologist as the affiliation agreement agreed to between the site and program. In other words, the level of expectation between extern and contractor is equivalent; there is not an added layer of expectations from an employer. I am concerned that programs are using language about employment as code for forbidding compensation in service of retention (preventing pay would reduce dropout, but a one year contract that runs the length of the externship counteract this, theoretically).

 

[psych.meout]

Think about why the DCT might be resistant to allowing prac students train at your site. Maybe if you were paying them out of your pocket and actively losing money in both time (e.g., supervision) and student pay there would be fewer (though not no) concerns. That you want to employ prac students (especially as contractors) makes it even less tenable, because you're looking to profit from their work even if you're kicking back to them some proportion of what you're being reimbursed for their labor.

Maybe if you were doing the former and actively losing out on this arrangement this talk of equity and fair labor practices would seem more genuine, but as it stands, trying to figure out how you can use prac students as contractors in your solo private practice makes this talk ring fairly hollow. If this is how you've phrased it to the DCT, it's no wonder they declined.

 

[PsyDr]

Can you clarify what you mean by this?

For some context, I have not yet offered this experience to any student or training program and am attempting to understand barriers to paying externs. Further, certain insurance companies in certain states allow billing for Master's level individuals who are receiving supervision from a licensed psychologist who is credentialed with that insurance.

Vaguely gesturing to legality in this way seems to be an attempt to paint extern compensation as some sort of ethical issue, and it does not appear to be keeping with the spirit of this forum.

I mean that you could accidentally commit a federal felony. Which you might want to consult an attorney about.

I was actually trying to get you to NOT document a lack of understanding or basic research in an area that could create real professional issues for you. These matters are easily identified on APA’s material and most federal rulings. Which you should read.

Federal law is very clear on the matter of trainees. As is the federal and professional definitions of supervision (I.e., on site at all times that services are given).

 

[clinton]

Think about why the DCT might be resistant to allowing prac students train at your site. Maybe if you were paying them out of your pocket and actively losing money in both time (e.g., supervision) and student pay there would be fewer (though not no) concerns. That you want to employ prac students (especially as contractors) makes it even less tenable, because you're looking to profit from their work even if you're kicking back to them some proportion of what you're being reimbursed for their labor.

Maybe if you were doing the former and actively losing out on this arrangement this talk of equity and fair labor practices would seem more genuine, but as it stands, trying to figure out how you can use prac students as contractors in your solo private practice makes this talk ring fairly hollow. If this is how you've phrased it to the DCT, it's no wonder they declined.

Thank you for your reply, and I regret not providing more details about payment/profit. I went for brevity in the initial post, but that totally left my intention open to interpretation. I will own my part (lack of clarity about intention) and hope you can acknowledge your assumption was a bit cynical (that my primary aim was profit from the work of others).

My hope was to only cover expenses (eg the extern's office space, advertising, added fees to my electronic health record). I have considered paying myself only for my time spent running the externship (estimated to be 2-4 hours per week at a discounted rate). I not was planning to take profit from the extern, but rather give back in a meaningful way (eg provide training, expand access to individual therapy, facilitate extern's valuing of self, and cut against the grain of unpaid service delivery for students) and diversify my weekly routine.

Is there a reason why pledging to lose income is a key ingredient of trust from a DCT? Is losing income the only form of equity in this scenario? I don't wish to land as snarky in my questions but am instead trying to challenge the notion that finances and the values of our profession are not incongruent.

 

[clinton]

I mean that you could accidentally commit a federal felony. Which you might want to consult an attorney about.

I was actually trying to get you to NOT document a lack of understanding or basic research in an area that could create real professional issues for you. These matters are easily identified on APA’s material and most federal rulings. Which you should read.

Federal law is very clear on the matter of trainees. As is the federal and professional definitions of supervision (I.e., on site at all times that services are given).

Thank you for clarifying. I will certainly clarify with an attorney and my malpractice insurance before proceeding.

 

[psych.meout]

Thank you for your reply, and I regret not providing more details about payment/profit. I went for brevity in the initial post, but that totally left my intention open to interpretation. I will own my part (lack of clarity about intention) and hope you can acknowledge your assumption was a bit cynical (that my primary aim was profit from the work of others).

My hope was to only cover expenses (eg the extern's office space, advertising, added fees to my electronic health record). I have considered paying myself only for my time spent running the externship (estimated to be 2-4 hours per week at a discounted rate). I not was planning to take profit from the extern, but rather give back in a meaningful way (eg provide training, expand access to individual therapy, facilitate extern's valuing of self, and cut against the grain of unpaid service delivery for students) and diversify my weekly routine.

I mean....

Is there a reason why pledging to lose income is a key ingredient of trust from a DCT? Is losing income the only form of equity in this scenario? I don't wish to land as snarky in my questions but am instead trying to challenge the notion that finances and the values of our profession are not incongruent.

My point is that when you stand to profit from an arrangement where you're employing students, it's going to be regarded with much more skepticism and hesitance than a situation where you gain nothing or even lose out from the arrangement.

For example, my current supervisor doesn't get paid based on the patients I see, they're only concerned that I'm getting the experiences I want out of this particular site. Moreover, they take a few hours of productivity out of their week to supervise me, coordinate things with other providers for me, etc. There's not even an apparent financial interest for them in this arrangement.

 

[WisNeuro]

For clarity, some insurers, including Medicare, will not reimburse for services if they are provided as a part of a training program. This is generally the limiting factor. Pretty much every non-VA that I have worked at, has taken a loss by having trainees. By and large, many of the faculty are spending unreimbursable time providing didactic experiences and supervision. If you are doing assessment you are almost always spending far more time than you can bill on reports and such. While I am all for more money for grad psych, the reality of the situation is that almost no one in legitimate training circumstances is making money off trainees.

 

[AcronymAllergy]

You'll also want to check to see if the are any stipulations in state licensing laws about being able to count pre-internship training hours for which a trainee is paid as actual training hours. If it's pay-for-service/hour pay vs. stipend pay, there may be differences.

I think it's great to want to give back, but I also think it's somewhat inaccurate to classify services provided by trainees at practicum sites as free. As has been mentioned, even if a trainee isn't paid directly by the site, they're still receiving a decent amount of non-monetary compensation in the form of the training experiences themselves, supervision, use of office space and resources, access to whatever didactics might be available, etc.

I'll add that at my graduate program, there were multiple off-campus training sites that did pay students through the graduate school via stipend. The sites also typically qualified the student for tuition remission. They usually required either a semester- or year-long commitment of some number of hours on-site per week (~20-30 in most instances), and the trainee had to sign up for practicum hours through the university. I don't know if any of the sites were at private practices, but this could be an option to look into. It'd almost certainly require a much closer relationship with the university than is often the case for a non-stipend site, though.

 

[summerbabe]

From a program perspective (and regardless of the compensation component), is the DCT even interested in adding more approved training sites? If they already have a lot of established relationships that provide quality training, the risk/reward of adding a new site might not be worth it since a poor training experience could be a significant setback for that initial student(s), especially if the training site is not adding to clinical experiences that are in shorter supply.

 

[kestrelcry]

I'll add that at my graduate program, there were multiple off-campus training sites that did pay students through the graduate school via stipend. The sites also typically qualified the student for tuition remission. They usually required either a semester- or year-long commitment of some number of hours on-site per week (~20-30 in most instances), and the trainee had to sign up for practicum hours through the university. I don't know if any of the sites were at private practices, but this could be an option to look into. It'd almost certainly require a much closer relationship with the university than is often the case for a non-stipend site, though.

At my program too. Our externships provided the money for our tuition, stipends, benefits, etc for that year. The program had contracts with: a community health program, a private substance abuse program, a children's hospital, a government-funded agency, and an in-patient unit somewhere. I'm pretty sure that the community mental health program was able to bill medicare for our services somehow; and we had to get an NPI number to provide services there. So we did a full calendar year at whatever site we were at for two days a week; the site paid the school; and that was our stipend, etc for the year. If we taught, that paid our stipend for the year, so it was either an externship or teaching. First and second year, the assistantships were within the school, no choice. After that, it was either externship or teaching. Most people taught one year at most, and you didn't have to; my last externship wanted me to stay a second year, but I wanted to teach, so I said no. I think most people were in for 5 years, that was about 3 cohort-worth of people with paid externships (minus the folks who taught and the folks who left after 5 years) and there were 6-8 students per cohort. So that's however many people that is of paid training positions. I had no idea it was rare until internship. My program may have been a misery, but that aspect was a huge plus.

 

[AlmostaPhD]

It was standard in my PhD program to have advanced students get their stipend/tuition remission from their paid clinical practica. This is also how things function where I am faculty now. We do have some volunteer sites for additional experience and folks see clients in the training clinic as a class and not a paid placement, but 1-2 years of training is funded from their clinical activities at community sites. I get that this is not the case everywhere, and it may depend on the schools in your local area, but until this message board I had no idea folks were spending significant time in unpaid clinical experiences in the field.

We also don't allow outside employment without permission, by which we mean waiting tables or something. If they are employed through the university to do teaching, clinical services, etc. as their assistantship that is totally kosher and in fact expected. There's a whole procedure for contracting with the university to provide this position and that makes it a university job and not a side job. I think the key may be contracting for a 12-month position with a set stipend vs. fee for service.

FWIW, I'd be happy to entertain interest from local private practices who want to start an externship. The main issues would be whether the program could staff it (enough students vs. slots in current placements), whether the training is a good fit for the school, and how much the practice is going to cover vs. faculty having to cover (e.g., I currently supervise one of our externships because there is no psychologist on site).

 

[WisNeuro]

At my program too. Our externships provided the money for our tuition, stipends, benefits, etc for that year. The program had contracts with: a community health program, a private substance abuse program, a children's hospital, a government-funded agency, and an in-patient unit somewhere. I'm pretty sure that the community mental health program was able to bill medicare for our services somehow; and we had to get an NPI number to provide services there. So we did a full calendar year at whatever site we were at for two days a week; the site paid the school; and that was our stipend, etc for the year. If we taught, that paid our stipend for the year, so it was either an externship or teaching. First and second year, the assistantships were within the school, no choice. After that, it was either externship or teaching. Most people taught one year at most, and you didn't have to; my last externship wanted me to stay a second year, but I wanted to teach, so I said no. I think most people were in for 5 years, that was about 3 cohort-worth of people with paid externships (minus the folks who taught and the folks who left after 5 years) and there were 6-8 students per cohort. So that's however many people that is of paid training positions. I had no idea it was rare until internship. My program may have been a misery, but that aspect was a huge plus.

If they did, I am pretty sure it was fraud. Medicaid, maybe, but not straight Medicare.

 

[AcronymAllergy]

If they did, I am pretty sure it was fraud. Medicaid, maybe, but not straight Medicare.

Not to get too far astray, but I also wonder if it was perhaps Medicaid, particularly given the CMH setting. The requirements I've seen typically state the licensed provider needs to actually be in the room with the trainee in order to bill (which was why a CMH clinic I trained at didn't bill for our services), but I suspect it can vary by state.

 

[WisNeuro]

Not to get too far astray, but I also wonder if it was perhaps Medicaid, particularly given the CMH setting. The requirements I've seen typically state the licensed provider needs to actually be in the room with the trainee in order to bill (which was why a CMH clinic I trained at didn't bill for our services), but I suspect it can vary by state.

As far as Medicare, the provision of the services actually has to be the licensed provider. I have definitely seen some sites who have erroneously stated that the requirements only state that they have to be in the room and the trainee can deliver the billed service, but the wording is fairly clear to me.

As far as Medicaid, many of its rules are actually set by the state, so I suspect that is what the poster was referring to in their comment. For example, my state allows Medicaid billing of eligible trainees.

 

[bcliff]

I completed paid practicum at a site (academic medical center) with a formal, two year fellowship program but no internship. The practicum closely mirrored the fellow curriculum (at a less intense level), and there were pretty rigid expectations for practicum students (e.g., 20+ hours/week of work, ideally a two year commitment, etc.). It was known to be intense, so students at my program had to receive approval from the clinical training faculty prior to beginning practicum there.

I think that the site preferred to keep trainees for two years (versus one) -- I speculate that that's why they offered a paid two year practicum and fellowship but never pursued an internship program. I think that offering $ to practicum students also helped to incentivize trainees to stick around for two years, although there wasn't anything "binding" practicum students to that arrangement. I'm also sure that the $ helped the site attract the practicum students they wanted. The program was one of the only paid opportunities in the region and was (not coincidentally) highly competitive.

It was a net positive experience for me, but I was coming from a flexible, small cohort grad program (and advisor, specifically) that was pretty open-minded on how students spent their time (assuming that coursework and milestones were completed well/on time). I'm also in a state with master's level licensure for psychologists, which was another prerequisite for this position.

I probably averaged 50 hours of work/week (total) during my time there, because I was balancing responsibilities at my host institution (e.g., coursework, teaching, internal practicum, peer supervision, milestones, etc.). Still though, I would do it again -- The financial security offered by that position was a major boost to my quality of life, despite the intense hours.

To the above points on CMS: I was specifically NOT allowed to work with Medicare patients. Whether someone did or did not have Medicare played a major role in which cases I was assigned.

 

[hhhzzzaaa]

I completed a paid practicum/ externship, and there are no issues with my site or my clinical PhD program. I signed a normal clinical training agreement that indicated that I would be paid hourly for my time. It was a great experience.