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Ease of setting up a psychiatry private practice?

Discussion in 'Psychiatry' started by Prime2000, Aug 9, 2009.

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  1. Prime2000

    Prime2000

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    Is psychiatry a field that is conducive to setting up an 8-5 type private practice? Is this a specialty where that goal is still attainable?
  2. whopper

    whopper Former jolly good fellow

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    Yes and yes.
  3. Doc Samson

    Doc Samson gamma irradiated

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    I second both of those yesses.
  4. sunlioness

    sunlioness Psychiatrist

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    Definitely doable. I'm in the middle of starting my own solo practice myself. It's a lot of work, but I'm having fun with it. After residency, I worked for a group practice where I just wasn't happy and while it's nerve wracking being on my own for so many reasons, it's also so nice being my own boss and setting my own schedule. I never anticipated all the little things though. Little things that cost money and add up. Like trash cans. Never in my life had to worry about whether my office had a trashcan in it and now I am going to office stores pricing trashcans. :laugh:
  5. ZuperZtar

    ZuperZtar

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    Wouldnt overhead be a LOT less than a PCP office? No EKG machines etc. Just a chair, desk, trash cans, etc. and a billing service and possibly a secretary. I would say in a cash only private practice, you could easily make 200k after expenses. Am I logical in my thought process?
  6. billypilgrim37

    billypilgrim37 Unstuck in Time

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    This is where a Costco and an Amazon Prime membership become key ;)
  7. medium rare

    medium rare Psychologist & Psych NP

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    Costco is a great place to set up credit card accounts for your practice. I've found their rates to be significantly lower than going through a bank, credit union, or other financial institution.

    I know many (most?) practitioners don't take credit cards, but if you're running a cash-and-carry, there are many benefits to accepting them.
  8. sunlioness

    sunlioness Psychiatrist

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    Oh yes, it's definitely a lot less. But I'm still being surprised all the time -especially by the cost of paying for my own health insurance. I'm not cash only because it takes too long to build a sustainable practice that way when most everyone has insurance that they understandably want you to take. The credentialing process has also been enlightening. :laugh: But I anticipate that after this lean period I'll be able to make a nice living for myself.

    And yeah, I definitely need to look into Cost Co.
    Last edited: Aug 13, 2009
  9. surftheiop

    surftheiop

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    How long would you say it takes to go from just starting the process of making your own practice to being in full swing with about your desired patient load? (I know it could depend on lots of things but just a general estimate)
  10. sunlioness

    sunlioness Psychiatrist

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    I'll have to get back to you on that one as I'm still in process. I am getting a lot of referrals though and have met some really cool therapists in the community. And it's helping that I am in the same community where I did residency and worked for a year. So those contacts are introducing me to more contacts. I haven't really done any formal advertising yet as I'm still getting the office set up, but I plan to once that is complete. I hope to have my own website up and make a brochure to give to local therapists and primary care offices. But all of that is still very much in process. I left the group at the end of June, shared office space with a friend of mine (a psychologist) on a limited basis for about 6 weeks and now am moving in to my own full time office. I'm also doing some informal peer supervision work with a local group of therapists and intend to explore doing some part time work with our local rape crisis center that offers counseling for victims of sexual trauma. There just aren't enough hours in the day, but I am making progress day by day. It's really exciting actually.
  11. worriedwell

    worriedwell Senior Member

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    setting it up is exceedingly easy...getting patients and maintaining a practice that is viable where you are getting paid is the hard part...and that is really all about business practice, and not too much about clinical skill. We don't learn that stuff in residency but it is key. Deciding in your location about insurance panels, marketing, hospital affiliation, other part time jobs that might help your practice, etc are all about business development. I think if you have the interest and motivation and are business minded, you will be more likely to succeed, but many people don't succeed (or at least don't flourish) if they don't know how to invest in their business properly (especially in areas where psychiatrists are saturated or if you decide not to take insurance). That being said, in many places, there is a huge need, and if you just want to do meds for psychologists and primary care docs and you take insurance, then you should be able to have a sustainable practice. It takes a ton of paperwork and a bit of time though to get on insurance panels so keep that in mind in your planning.
  12. Prime2000

    Prime2000

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    I hear that generally there is a shortage of psychiatrists in most areas. I assumed getting patients was not difficult?
  13. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    As others have mentioned, getting patients is easy. Getting paying patients is more difficult.
  14. drpsychmd

    drpsychmd

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    I would guess this is location-dependent. I imagine it would be more competitive in a big city, but how will that affect income? Say I wanted to set up a PP in washington DC, how would that compare (income/traffic-wise) to a PP in a rural town with little/no psychiatrists?
  15. carlosc1dbz

    carlosc1dbz Loves Christina Aldana!

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    Good question, I wonder if the patient loads would be the same or different depending on rural vs city. One thing I dont get is if a place is rural, do you get higher reimbursement?
  16. whopper

    whopper Former jolly good fellow

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    I've been doing private practice for 2 months.

    You are your own man (or woman) in private practice. That's good and bad. If you miss something, no one will be there to catch it except the patient.

    You have to be mindful of the costs. You are running the business. Things like getting the snow shoveled all of a sudden are problems you have to worry about.

    You are a boss. That creates another set of headaches.

    You don't push patients along, you don't make more money vs other types of work (e.g. hospital, community mental health) unless you charge out of pocket charges that are more expensive than the insurance rates.

    Now this is the really really bad thing: insurance panels. I have a floodgate of patients wanting to see me but I'm still waiting for some insurance companies to approve me. I've submitted my applications months ago---on the order of 6 months. I'm still waiting on some of them.

    The good thing I'm enjoying from it is if I do this right (and this is not happening now), I could potentially make a lot of money off of it while doing work I love, while also giving good care. Right now I don't have enough patients to reach that sweet spot.

    I've said this before in other posts but I'd recommend against doing private practice as moonlighting as a resident unless it's with a group practice who only has you doing it for limited hours. Definitely do not do it if you are running it. I think it's a highly realistic scenario to possibly even be losing money the first few months of private practice if you're having this insurance panel bull I'm dealing with now.

    For me, I'm not in a bad situation because I got a pseudo-promotion at the state job that I'm doing in addition to private practice. I've been put into a position where I don't have to do much (I have about 16 hours a week with nothing to do but I have to be in the facility. That is in addition to giving good care I'm proud of, I've actually volunteered to teach a class to the psychology grad students and I still have time on my hands. Maybe an Xbox at work?).

    I'm going to have a talk with the guy who owns the private practice, and I'm going to tell him if things don't pick up in 2-3 months, I might leave the private practice, or cut my hours with him so I can pick up hours at a place I moonlighted at fellowship that wants me back. I was earning very very good money there.
  17. sunlioness

    sunlioness Psychiatrist

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    I am actually looking to get out of solo private practice. I think working with a group would be fine if you're sharing costs and can afford some administrative support, but doing it all by myself has proven way too isolating and frustrating.
  18. fiatslug

    fiatslug Senior Member

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    re: getting on insurance panels... is the process any easier/faster if you're already paneled as a hospital employee? (not as a resident, as an attending...)

    I'm in my first job out and I love having senior colleagues all around me (as well as other fresh-out docs). I would want to start out in PP, but I know many from my residency who did (in fact, several are in a loosely knit group practice, which would be lots of fun).
  19. sunlioness

    sunlioness Psychiatrist

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    I was paneled when I worked for a local group practice, but when I went solo it still took forever. Now that could be because I didn't know what I was doing and had to muddle through it. If you hire an experienced biller, they might be able to expedite things a bit.
  20. whopper

    whopper Former jolly good fellow

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    As far as I know....no.

    I've already been in 4 hospital systems in the last 4 years. It didn't make any difference.

    I'm doing private practice in a practice full of psychologists. So I'm a golden goose and they're kowtowing to me. The office manager has done so much of the dirty work I would've had to have done myself if this were my own private practice.

    Going through the insurance panels is like pulling out your teeth with a pair of pliers. There's a bunch of jargon and questions. Several of the questions I answered, I didn't know what was going on. The office manager guided me through it.

    Despite that, this has still been a pain in the butt, and 2 major insurance companies are claiming that they never received my documentation even though we've mailed it to them via certified mail, and faxed it to them with receipts that they've received it. Another example: I get a letter from an insurance company demanding that I prove I have expertise in a certain field, and they say they want a response by August 15. The letter was sent out August 16. It says in the letter that if they do not hear from me by the 15th, then they will not consider that I have expertise in the field I wrote that I did. (and by the way, I already handed them my CV more than once that already answers their question!)

    I've had some patients pay me out of pocket even though they're insured by these companies because they can't wait any longer to see a psychiatrist. That in turn puts a big guilt trip on me, that in turn frustrates me much more because I'm not earning more by seeing them than I did in my moonlighting gig where I didn't have to worry about all this insurance bull. I just had to see patients----period. I didn't have to waste half my time jumping through their idiotic hoops.
  21. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    for some insurance panels, it is easier. It was very easy for me when I left the local university to stay on the BC/BS panels.
    The medicare and medicaid transfer paperwork was complicated.
  22. pingouin

    pingouin just chillin' Administrator SDN Senior Moderator

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    It was easy for me to stay credentialed on BC/BS when I switched from a CMHC to private practice (therapist, not psychiatrist), but getting the billing right was a nightmare for a while.

    The CMHC had two addresses, and when I billed from my new private office, they sent the reimbursement checks to the CMHC (which was polite enough to CASH THEM even though I hadn't worked there in almost 2 years). Somehow BC/BS had managed to deactivate in their system the address I had just given them.

    Took multiple phone calls to straighten it all out, but once I did things were smooth.
  23. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    It's nice working for a large employer--fill out one stack of forms when you're hired, sign where told to...someone else makes sure it stays up to date.
  24. sunlioness

    sunlioness Psychiatrist

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    That sounds like a slice of heaven. Not to mention health benefits, paid liability insurance and a prescribed sum of money being put directly into my account at regular intervals. Private practice is for the birds. (At least right now it is). :)
  25. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    We're hiring... :D
  26. medium rare

    medium rare Psychologist & Psych NP

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    I really enjoy private practice; no administrative BS to put up with and no outsiders telling me how to do my job - I run a lean cash-and-carry practice.

    I don't take insurance and don't deal with the BS that any carrier tries to put in front of me. My office manager will file patient claims as a courtesy if the patient has out-of-network benefits, but I don't accept assignment and the reimbursement (if any) goes directly to the patient. It is the patient's responsiblity to check with their carrier to see if they have out-of-network benefits and what percentage of the charge the insurance pays. Yes, as mentioned in many prior posts, trying to deal with insurance is a major pain in the ass - which is why I don't bother.

    The patient is responsible for payment of my fees at the time of service. Occassionally, I will invoice a patient if they request, but only after I inform them that they must pay their monthly bill in full within 30 days of invoice and have them agree to this in writing. Otherwise, I will not see them again until their bill is paid. Taking credit cards has been VERY helpful in getting paid at TOS.

    I say this because I am NOT a business-minded person. I had to learn much of this the hard way and after consultation with many folks who had been doing this for a long time. Private practice is clearly not for everyone, but it can be rewarding, very profitable, and - dare I say - fun.
  27. heyjack70

    heyjack70 Junior Member

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    Can anyone who has had success in private practice recommend some good books, or other resources, that you found helpful?
  28. Manicsleep

    Manicsleep

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    The best resources are people in the community where you are.

    Having moved around initially within the state, I found that every community is a little different and sometimes a lot different.
    So it is better to ask the physicians around you. This includes psychiatrists as well primary care doctors. It is also a good idea to get in touch with some of the social workers and psychologists because they're often having trouble finding a psychiatrist.
  29. carlosc1dbz

    carlosc1dbz Loves Christina Aldana!

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    How well did your residency program prepare you for setting up a private practice?
  30. CaliforniaGreen

    CaliforniaGreen

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    What were the main factors in making you leave private practice? I hear the first year is hard, were you in it longer than that?
  31. CaliforniaGreen

    CaliforniaGreen

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    I wonder this too. How can you decide on a good location (if you are flexible) to set up a practice? What makes one suburb more profitable that another, and how do you determine this?
  32. sunlioness

    sunlioness Psychiatrist

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    Just over a year. The only thing I liked about solo practice was being able to set my own schedule. Other than that, it was for the birds. I think someday I might enjoy a private practice with a group of at least a few other physicians, but solo was just way too isolating and I don't like running my own business or being on call 24/7. I did pretty darned well money-wise for only being at it a relatively short while and for having my first biller turn out to be utterly incompetent, but I pretty much disliked every minute of it and therefore was never motivated to work the extra bit you need to in order to make the good money. I'd rather work for someone else, have my health benefits, have my paycheck automatically deposited at regular intervals, be around other docs, have someone else pay for my administrative help, and be able to do some clinical teaching (which I really love and really missed). I'm grateful to have the opportunity to get back into academic medicine.

    Bottom line, solo private practice just fundamentally was not a mesh with my personality. I'm probably not the best person to talk with in regards to what little things are difficult for people who overall like this environment. I just didn't like the whole package.
  33. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Where's that "Like" button on this thing?
  34. Chimed

    Chimed

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    That is one of the main reasons I will not likely go into private practice. Being in child, I'll admit the amount I could make in private practice is appealing, especially when I look at my student loans :)eek:). But I love the team approach to patient care and would miss the team meetings, the debates on the best patient care, working with medical students and residents, and being able to walk down to my colleagues office and shoot the breeze. It would be too isolating for my taste. The pay will be lower, but I'm going into academics for a lot of those reasons. But academics has its own draw backs...
  35. whopper

    whopper Former jolly good fellow

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    I've been doing the private practice thing for 4 months now. Things have picked up and now I'm making good money at it. I think I got the gist of it but I'm still contemplating leaving.

    A guy with a private practice he owns wants me to take over his practice. It's in the heart of a metropolitan area and he gets referrals out the wazoo because of it's location. The place I'm at now, it's not my own practice. They take a cut of what I earn, though I don't have to worry about the usual office bullspit like making sure the sidewalks are shoveled.

    I'm still trying to figure all of this out. I got 5 job offers, each of them very good and paying very well. I can't do all of them. Taking one nixes the others.
  36. Chimed

    Chimed

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    whooper, you strike me as someone who would be drawn to teaching. Are you associated with an academic center? If not, what was your thought process?
  37. CaliforniaGreen

    CaliforniaGreen

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    I can definitely see that one could miss out on some of the benefits of being in medicine while working on his/her own in private practice, but what is the realistic income difference in private vs non-private we're talking about?
    Last edited: Oct 30, 2010
  38. whopper

    whopper Former jolly good fellow

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    I've been offered a few teaching positions. I was asked to work where I trained in general residency and was told I would teach residents, I've been asked by my fellowship to work for them, a local television station wanted me to be their medical television personality. I've turned most of them down, not because I don't want to teach but because taking them would've locked me into a job position that closed off other possibilities I wanted to explore. I haven't turned down the TV gig yet but I'm in a position right now where I'm thinking the cons outweigh the pros.

    E.g. If I worked for a university hospital as a professor of general and forensic psychiatry, now I can only work through that hospital. I can't do private practice, I can't work for the community mental health center on the side, etc. I'm basically their employee and can only do what they allow me to do.

    I wanted to try several ventures and I haven't yet locked onto something yet that's had me consider settling down. As of right now, I still consider myself green in some areas I want to explore. I've also had some job offers where the pay is through the roof. Working for a place where I'd be given a teaching position would prevent me from taking the high pay jobs.

    I am assigned to teach psychopharmacology to a local college but it's outside a medical curriculum and it doesn't start for a few months.
  39. toothless rufus

    toothless rufus

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    Why would one need to be on call 24/7 in private practice? What about the ER?
  40. sunlioness

    sunlioness Psychiatrist

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    That doesn't really fly. There are urgent issues that come up that don't necessarily merit an ED visit. Crisis services that are affiliated with hospital systems are a bit better (and my voicemail made reference to both the ED and a crisis line), but still sometimes a patient does really need to speak to a physician urgently outside of normal business hours. I had colleagues who were also in solo practice and we would cover each other for vacations and such, but mostly it was just me on call 24/7. Most days people didn't call and calls in the middle of the night were exceedingly rare, but always knowing they could (and having several of these calls actually not constitute true urgent issues, but rather just people being impatient) and feeling physically tied to my cell phone wasn't pleasant for me.
  41. CaliforniaGreen

    CaliforniaGreen

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    I was also under the impression that many solo psychiatrists either have patients go to an ER or wait for normal business hours. I imagine that the on-call feature of a practice could easily be taken advantage of. Maybe I am wrong, but were you just being too nice and accommodating? I thought most psychiatrists don't offer 24/7 call. I also wonder if this is as much an issue with child psych.
  42. sunlioness

    sunlioness Psychiatrist

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    Many do, but I think they're taking a risk. The ED oftentimes just isn't what's indicated. What came up most commonly was disorganized folks who didn't realize they were out of their meds. Normally, it might be okay to wait until business hours, but say you're a fairly brittle bipolar or physically dependent on benzos or something like that and it's a Friday night. They don't need to go to the ED right then, but they do need their meds before Monday or they might very well end up needing the ED. Yes, patients should keep better track of their prescriptions and request refills before 6pm on a Friday evening when they only have one pill left and most of them do. But you're still liable if you're unavailable (or haven't arranged for appropriate coverage) to the ones who don't and something bad happens to them.

    As for me being "too nice", it's possible. I did get less nice as time went on. I didn't answer any phone calls directly and let everything go to voice mail. The voice mail gave the standard ED/911/crisis line info and then specifically said that anyone leaving routine office requests, other things that weren't actually urgent, or if they didn't state an explicit detailed reason for the call (for instance, "this is Joe. It's an emergency, please call me" was not going to fly*) that I wouldn't get back to them. And I didn't.

    *Learned that one the hard way. After you call back a few "emergencies" right away only to find that the emergency is they can't remember their next appointment time and you don't have your schedule at home anyway . . . well, I didn't do that anymore.

    Edited much later to add that I also had my main office voice mail explicitly state that the urgent number was ONLY for the use of established patients. Because every now and then I'd get calls on that line from potential patients who thought that their need to schedule with a psychiatrist immediately was an emergency.
    Last edited: Oct 30, 2010
  43. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    Some specialties can get away without offering 24/7 call (this varies by geographic location and insurance type). But in most areas, it is the standard of care for a psychiatrist to offer 24/7 coverage.
  44. Chimed

    Chimed

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    It amazes me how often we get patients in our psych ED who can't get a hold of their psychiatrist because they don't take call for their own patients. It can become a real mess for us when we have a patient with suicidal ideation and we can't get a hold of their psychiatrist to get collateral information or coordinate follow-up care to try to avoid an expensive hospitalization that may not be necessary.

    To the other poster, it's not about being "nice", just standard of care to take call for your patients.
  45. whopper

    whopper Former jolly good fellow

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    At the private practice (PP) where I work, I get about 5 calls a week. None of them are emergencies (so far). That's with me only working about 16 hours a week doing PP.

    The typical calls are to the effect of...
    "I'm getting a side effect, what do I do?"
    "Can I get a refill on the (insert benzo here)?" (Usually in this case they used it up all in a week even though it was supposed to last a month. I pretty much always answer no and remind them that any of my patients on a benzo will be weaned off. I give an information brochure to all my patients on a benzo telling them they will only be on it temporarily and why).
    "Does it matter what time I take the pill?"
    "I'm on this other medication, will the two medications interact?"

    These certainly do not merit an ER visit except for the benzo question, where the person may have a dependence problem. In those cases, I tell the patient if they are suffering from withdrawal, they need to go to an ER.
  46. digitlnoize

    digitlnoize Rock God

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    Can anyone talk about what employees they have in a solo practice?

    Is it just a receptionist, or does your receptionist also have some medical background (med tech, RN?) Do you have any other staff, medical or otherwise? Biller? Office manager?

    How do you handle security at the office?

    I'm also curious about salaries. I've looked at all the salary surveys and read around here, but I'm mostly curious about the difference in salaried community vs private mostly insurance vs private mostly cash only. Anyone got any numbers?
  47. Manicsleep

    Manicsleep

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  48. Chimed

    Chimed

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    Great post. :thumbup:

    For the "Flexibility/Control" section, I would add that if you have a split clinical/research set up, you actually have a fair amount of flexibility. I know researchers who only work 50% in clinical practice during the week and can basically set up the rest of the week however they want. If they need to leave to pick up their kid from school or go to the dentist on the research days, there's no problem.
  49. Manicsleep

    Manicsleep

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  50. whopper

    whopper Former jolly good fellow

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    Wow, great discussion and several of the things mentioned here are so true.

    I work for the state, and true to the above, I think the money sucks. I'm doing private practice too. That makes more money but then I got to worry about business stuff.

    I think if you do PP the thing that makes it worth it is you got to have staff you can rely on. The guy I know that wants me to take over his practice told me he went through several office managers until he found one he felt be could trust.

    How much? I'm talking like Kirk or Picard and his crew. I'm figuring this out now. There's a type of person who takes a job and only sees it as a job. Then there's someone who works and takes it seriously, takes their responsibilities seriously and when you're working with them you can count of them to have their t's crossed and their i's dotted.

    If you don't have this type of person working for you, you're screwed. You have to start worrying about every little thing because you can't rely on this person to do their job that ultimately is your responsibility.

    But if you do find this type of employee, you're going to have a lot of responsibility to them as well. If you do PP, you just can't leave this type of practice and let such an employee hang there if they've worked for you for a long duration. That's what's going on with the guy that wants me to take ovr his practice. He's got golden employees and he wants me to continue to take care of them as they've taken care of him.

    So, that really does signify to me if I take his place over, I'm walking into something very serious, and it makes this decision all the more heavy as to whether or not I'm going to take it over.

    Yes. This is true. Just to give one example, there's another psychiatrist at the place I work. The guy's patients have been psychotic for months and he still hasn't done a forced med request. If a guy is psychotic and meeting the criteria for forced meds, I do the forced med request within the same day the patient refuses. His patient turnover rate is a joke compared to mine and I know why. The staff and the state have to pay for this guy's mess because they got to deal with a psychotically dangerous person day-to-day and the state has to pay for these people being in the hospital for several more months before they clear up. How much? Only about $800 a day. I figure due to his incompetence, it costs the state at least a few million a year. How many doctors are like him? Plenty.

    If someone's lazy, working in a place like the state can be a cush job.

    I will say, however, that I've gotten some great cases on a forensic unit. I watch the news, and about once every few weeks, the guy on the headline is my patient. I've had murderers, rapists, what have you, and I've also had some great experience that allowed me to sharpen my skills. The benefits are usually good. Many state jobs are such that you'll get a pension worth half your salary for the rest of your life. If you're someone that's passionate about psychiatry, working for the state IMHO could still be an option. If you do a good job, you can rise among the state ranks to administration.

    Or there's another option. You can do the state and PP. That's what I'm doing now. I'm still trying to flesh out if this will be my permanent path.
    Last edited: Nov 5, 2010

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