Is there a shortage of psychiatrists or it it just where I live?

[birchswing]

Is it normal for there to be no doctors groups (like near me we have Riverside, Sentara) that have psychiatric practices? For example, within both of those organizations (which are the big healthcare groups in my area), there are cardiologists, endocrinologists, neurologists, etc. And in my experience seeing those specialists, they're great. You can get in same week usually, the specialists spends about an hour with you, they're very intelligent, etc.

But neither of those two groups has a psychiatry practice. Their hospitals don't even have psychiatric beds—I'm pretty sure if you needed one you'd have to go about an hour in either direction of where I live to find a hospital that has them. All of the psychiatry practices near me are not affiliated with those larger organizations. It's just 1-3 people working in an office. Why is that? And why aren't there any US doctors in psychiatry whereas there are in all other fields in my area? Almost all of the psychiatrists where I am are from Pakistan, Iran, or Iraq. That can't be a coincidence because I don't live in a very diverse area, and I can't think of any other foreign med school doctors in any other specialty. The therapists in those offices are all from the US.

My dad has a theory that it has to with reimbursement rates. For example, based on my reading of our insurance statements it looks like my endocrinologist gets a few hundred dollars every time I see her, whereas my psychiatrist gets about 60-70. If it meant having more and better psychiatrists, I would be all for them getting paid more!

The reason I realized all this recently is that I am trying to find a local psychiatrist I can see more often. I currently see one about an hour away and can't get to her as often as I want to. No psychiatrist in my town is taking new patients or they're not taking them until September at the earliest. I came across one who is taking new patients starting in September but you have to fill out an application first. I filled it out, but I have no idea what he is looking for in a patient. It's not a patient's market! And I don't live in the boondocks. I live in a small college town (the college does not have a psychiatrist, either). I don't really want to say which town, although I'm not sure if it matters for answering these questions.

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[vanfanal]

Just a med student - but based on what's discussed on this forum, I would say your comments about compensation are quite right. This is why lots of psychiatrists run cash -only practices so that they can spend more time with patients, but also not get ripped of by insurance reimbursements. It is said that there's quite a shortage of psychiatrists.

 

[notdeadyet]

You are right. There is a psychiatrist shortage almost everywhere. This is true even in cities where there is a "surplus" of psychiatrists, since in these cities many are cash only practices that exclude most patients, furthering the shortage.

Psychiatry has about 40% non U.S. trained. This is due mostly due to it being a non competitive specialty. This is likely to start changing in the near future as med schools domestically increase in size and number while residency slots stay the same number.

 

[BestDoctorEver]

Psychiatry has about 40% non U.S. trained.

That is low...

 

[notdeadyet]

That is low...

You think? Last I looked, the NRMP data showed about 50% of psych residency matriculants were non-U.S. allopaths. So that 50% contains DOs too.


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[birchswing]

You are right. There is a psychiatrist shortage almost everywhere. This is true even in cities where there is a "surplus" of psychiatrists, since in these cities many are cash only practices that exclude most patients, furthering the shortage.

Psychiatry has about 40% non U.S. trained. This is due mostly due to it being a non competitive specialty. This is likely to start changing in the near future as med schools domestically increase in size and number while residency slots stay the same number.

Well, as xenophobic as it sounds, I would be glad to see more US trained psychiatrists, but I'd also like more in general. I don't know much about ObamaCare, but isn't there something in it where mental health has to be treated the same as other illnesses? I wonder if that will increase reimbursements?

 

[birchswing]

That is low...

Where I live 7/9 have their degrees from the Middle East. The 2 that are US trained are in their 80s and I do not believe should be practicing medicine.

 

[BobbyB]

Is it normal for there to be no doctors groups (like near me we have Riverside, Sentara) that have psychiatric practices? For example, within both of those organizations (which are the big healthcare groups in my area), there are cardiologists, endocrinologists, neurologists, etc. And in my experience seeing those specialists, they're great. You can get in same week usually, the specialists spends about an hour with you, they're very intelligent, etc.

But neither of those two groups has a psychiatry practice. Their hospitals don't even have psychiatric beds—I'm pretty sure if you needed one you'd have to go about an hour in either direction of where I live to find a hospital that has them. All of the psychiatry practices near me are not affiliated with those larger organizations. It's just 1-3 people working in an office. Why is that? And why aren't there any US doctors in psychiatry whereas there are in all other fields in my area? Almost all of the psychiatrists where I am are from Pakistan, Iran, or Iraq. That can't be a coincidence because I don't live in a very diverse area, and I can't think of any other foreign med school doctors in any other specialty. The therapists in those offices are all from the US.

My dad has a theory that it has to with reimbursement rates. For example, based on my reading of our insurance statements it looks like my endocrinologist gets a few hundred dollars every time I see her, whereas my psychiatrist gets about 60-70. If it meant having more and better psychiatrists, I would be all for them getting paid more!

The reason I realized all this recently is that I am trying to find a local psychiatrist I can see more often. I currently see one about an hour away and can't get to her as often as I want to. No psychiatrist in my town is taking new patients or they're not taking them until September at the earliest. I came across one who is taking new patients starting in September but you have to fill out an application first. I filled it out, but I have no idea what he is looking for in a patient. It's not a patient's market! And I don't live in the boondocks. I live in a small college town (the college does not have a psychiatrist, either). I don't really want to say which town, although I'm not sure if it matters for answering these questions.

psychiatrists have low startup costs and overhead so they don't need to team up with other doctors to have a private practice. they can make their own.

inpatient psych doesn't bring in the big bucks. high uninsured patient rates and low Medicare reimbursement.

I'm from southern California and my local behavioral health center has >50% white attendings/residents. it could be because Indians and Middle Eastern people prefer living on the East Coast for some reason.

 

[BestDoctorEver]

Where I live 7/9 have their degrees from the Middle East. The 2 that are US trained are in their 80s and I do not believe should be practicing medicine.

Why not if they are mentally capable...

 

[birchswing]

Why not if they are mentally capable...

That's a very fair question.

I am frustrated generally by the lack of psychiatrists and the lack of good psychiatrists, and I suppose that rather than relate my experiences with them (which is starting to cross a boundary of what this forum is about), I am using shorthand and stereotypes to bolster my complaint that my area has poor psychiatrists, in this case by relying on the stereotype of old being bad and also before with the idea that FMGs are bad psychiatrists. Neither is necessarily true.

In this case, I believe it is true. One of the two I mentioned missed more appointments than he kept, and looking him up now on ratemds.com that still seems to be true. He was disorganized and at times confused. His wife acted informally as his assistant and would be the one who would actually do a lot of the work. I'm not entirely sure how legal it was or is. He prescribed benzodiazepines as first-line treatment for anxiety. And he made false claims to me. He put me on Klonopin and told me it was an anti-convulsant, that it was not addictive, and that it was like an antidepressant version of Ativan. I was suspicious, and I told him I didn't want to get stuck on anything. He said he had patients on it for 20 years and that they were fine. This was unfortunately before I started looking things like this up on the Internet to double-check what a doctor told me.

The other one I mentioned was "with it" to a greater extent, but he was not a good psychiatrist for other reasons. For one thing, he also didn't believe benzodiazepines are addictive. He would not order blood tests that are indicated with certain medications. And he is known in our town as the one you go to to get whatever you want. He would end our sessions by saying, "Do you need anything else?" While that may sound nice if you were a drug seeking person, he also had a nasty temper and called me some inappropriate names once, which is when I decided to stop seeing him. Both of them using benzodiazepines as first-line treatment.

In this case, I just don't believe they were up to date with other treatments. I see a good one now, but it's a long drive and hard to get appointments. But worth it for the time being. It just struck me that if I want to see a really great cardiologist or even primary care doctor I don't have to travel so far or wait so long. And when it comes to making med changes, it's very nice to be able to see someone more often.

 

[Ceke2002]

Things were really bad here going back a few years now. The average wait time to see a Psychiatrist was anywhere from 5 to over 12 months; I know of at least two Schizophrenic patients who were so desperate for treatment they couldn't access, that they either walked into the middle of an emergency department, or stood on the steps of the local State Psych Hospital and literally opened their arms up with a razor in the hope that someone would 'hear' them; due to the lack of beds and services as well it wasn't uncommon to also have floridly psychotic adult patients being placed in with adolescent units simply because there were no beds available for them in more suitable surroundings. In short, it was pretty much a total mess. Then we had a change of Government, more funding was put into frontline 'crisis' services to get severely mentally ill people the help (and stabilisation) needed before it escalated to an overcrowded hospital beds situation, and they also bought in a scheme where the 'worried well' (people with simple life stress problems, mild depression and anxiety, etc) could get access to Psychology services at a fixed lower rate than before. Just to side step a moment, the way our system works most Psychiatrists bill through medicare, and we pay a 'gap fee' or a percentage of the overall fee and then the Psychiatrist claims the rest from the Government (or vice versa, we pay the full fee up front and then get reimbursed). Before the new Psychologist access system came in there was no medicare rebates available if you wanted to see a Psychologist, so a lot of people who probably really didn't need to be in the Psychiatric system would go there anyway, simply because out of the two options that was the more affordable. Once the new system was in place it freed up a lot of Psychiatric placements that wouldn't have otherwise been available. Anyway, since then the average wait time to see a Psychiatrist as a private patient (ie still billed through medicare, but not considered to be in the Government system) has been reduced to around 3-6 months - a huge improvement all round, although things still aren't ideal and a number of patients do tend to fall through the cracks. We've also since had another change of Government and it still remains to be seen if they'll improve or ruin the current system in place.

 

[SteinUmStein]

Ceke you had me incredibly confused until I saw your location. Maybe when asking/answering these questions we might specify where we are talking about since these issues vary greatly across countries and even regions within countries.

 

[Ceke2002]

Ceke you had me incredibly confused until I saw your location. Maybe when asking/answering these questions we might specify where we are talking about since these issues vary greatly across countries and even regions within countries.

Ah, sorry, my bad. I've mentioned a number of times before that I'm from Australia (South Australia specifically), I guess I just wrongly assumed that it was common knowledge. I will endeavour to be more aware in future. You're right, with questions like these it can be confusing if locations aren't made clear.

 

[SteinUmStein]

Ah, sorry, my bad. I've mentioned a number of times before that I'm from Australia (South Australia specifically), I guess I just wrongly assumed that it was common knowledge. I will endeavour to be more aware in future. You're right, with questions like these it can be confusing if locations aren't made clear.

Oh no problem, it's my fault - your location is clearly marked on the left. I just read your post thinking:

 

[vistaril]

Is it normal for there to be no doctors groups (like near me we have Riverside, Sentara) that have psychiatric practices? For example, within both of those organizations (which are the big healthcare groups in my area), there are cardiologists, endocrinologists, neurologists, etc. And in my experience seeing those specialists, they're great. You can get in same week usually, the specialists spends about an hour with you, they're very intelligent, etc.

But neither of those two groups has a psychiatry practice. Their hospitals don't even have psychiatric beds—I'm pretty sure if you needed one you'd have to go about an hour in either direction of where I live to find a hospital that has them. All of the psychiatry practices near me are not affiliated with those larger organizations. It's just 1-3 people working in an office. Why is that? And why aren't there any US doctors in psychiatry whereas there are in all other fields in my area? Almost all of the psychiatrists where I am are from Pakistan, Iran, or Iraq. That can't be a coincidence because I don't live in a very diverse area, and I can't think of any other foreign med school doctors in any other specialty. The therapists in those offices are all from the US.

My dad has a theory that it has to with reimbursement rates. For example, based on my reading of our insurance statements it looks like my endocrinologist gets a few hundred dollars every time I see her, whereas my psychiatrist gets about 60-70. If it meant having more and better psychiatrists, I would be all for them getting paid more!

The reason I realized all this recently is that I am trying to find a local psychiatrist I can see more often. I currently see one about an hour away and can't get to her as often as I want to. No psychiatrist in my town is taking new patients or they're not taking them until September at the earliest. I came across one who is taking new patients starting in September but you have to fill out an application first. I filled it out, but I have no idea what he is looking for in a patient. It's not a patient's market! And I don't live in the boondocks. I live in a small college town (the college does not have a psychiatrist, either). I don't really want to say which town, although I'm not sure if it matters for answering these questions.

1) Psychiatry has a lot of foreign trained people from the middle east and other places because it has one of the lowest US match %s. It has one of the lowest US match %'s for a combination of having the lowest pay, lowest prestige, complete lack of procedures, etc....iow, it's what more people from overseas can get into. If things were to somehow change and ent by some miracle became very noncompetitive, you would see a lot of imgs in that too.

2) Psychiatry doesn't have as many large groups as other fields because equipment, start up costs, overhead, etc is very low. This is *not* a positive, however. Framing it as a negative that it takes a lot of capital to open up an eye surgery center is is pretty silly- the large amount of REVENUE more than offsets the large amount of capital. That's about like a guy living under a bridge bragging about his 'low utilities' relative to the guy with the 4000 sq ft house. Well yeah.....

3) I don't know any specialists in medicine or surgical subspecialties that spend an hour with the pt. Maybe if it's a consultation before some complicated and massively reimbursed procedure. But that time spent is time essentially that should be counted towards the reimbursement in the very well compensated procedure. Psychiatry, even in high volume 'med check' insurance practices, still spends far more time on average than physicians. A 'fast' outpt psychiatrist may spend 7-10 minutes face to face with a pt, whereas the equivalent internist may spend 1.5-4......

 

[dl2dp2]

A 'fast' outpt psychiatrist may spend 7-10 minutes face to face with a pt, whereas the equivalent internist may spend 1.5-4......

Your hyperbolics are getting out of control lol. I dare you to be an outpatient internist who spends 1.5 minutes seeing a patient.

 

[birchswing]

3) I don't know any specialists in medicine or surgical subspecialties that spend an hour with the pt. Maybe if it's a consultation before some complicated and massively reimbursed procedure. But that time spent is time essentially that should be counted towards the reimbursement in the very well compensated procedure. Psychiatry, even in high volume 'med check' insurance practices, still spends far more time on average than physicians. A 'fast' outpt psychiatrist may spend 7-10 minutes face to face with a pt, whereas the equivalent internist may spend 1.5-4......

I guess anecdotes don't make great evidence, but I spent an hour and a half talking to my PCP yesterday. I even asked him to act as my psychiatrist (which I've asked many times before). He won't go that far, but he is wonderful. He saved me once when my pulse was in the 160s and not coming down, and my psychiatrist thought it was from anxiety. The psychiatrist told me there was no amount of Ativan that was too much to take if it hadn't yet become therapeutic (this was the second old guy I mentioned). My PCP gave me Inderal and sent me to a cardiologist, and I actually got better instead of more addicted. He doesn't leave his office till 7 most nights, and I think his day is supposed to end around 4. Granted, I wait to see him in the waiting room about an hour, but it's well worth it. With other specialists like my endocrinologist and cardiologist, I never feel rushed, and it seems like I am seeing them a good while. At least a good half hour or so. With the psychiatrist, even when she is generous with her time (she's gone up to a half hour), she's harried and rushed and taking the next one back as we're saying goodbye. When you talk with a PCP long enough, things come out that don't in a shorter visit. He's the perfect doctor for me: intelligent, not threatened by my intelligence, he's curious, etc.

 

[SteinUmStein]

Re: Vistaril -

Low overhead and low startup costs *are* a positive. Whether it ultimately results in more or less net income is a separate matter, but the low overhead itself cannot be construed as a negative. It's nonsensical. Anyone with a background in business will tell you low overhead is a very good thing. Psychiatry will be one of the last specialties that is easily capable of independent/small-group practice outside a hospital system thanks to its low overhead costs.

And we're still waiting on that data to support your multiple posts stating that psychiatry has the "lowest income in medicine". If you do post your sources, please correct for average hours worked. Your perspective, as always, is appreciated.

 

[vistaril]

Your hyperbolics are getting out of control lol. I dare you to be an outpatient internist who spends 1.5 minutes seeing a patient.

In private practice, lots of internists who treat patients for chronic disease schedule followups where they have already reviewed the results of the pertinent labs before going in with patients(lipds, glycemic labs, chem) and have a medical assistant or rn see the patient first(while they are seeing pts in other rooms)...they'll quickly ask the nurse before going in if there are any new complaints. if not they aren't going to go in and repeat all the questions. They'll simply go in, say "you're cholesterol and blood sugar labs are looking good. But we have to bring your blood pressure down a little more so we are going to increase one of your blood pressure meds". The medication has already been printed off by the computer and they've already signed it and they are out...usually in a minute or two.

I've taken my grandmother to 2 different outpt geri appts with 2 different providers and both were under 1 minute of face time with the internist/geriatrician. She spent additional time talking to others of course(but not a PA/NP). If you don't believe this is commonplace in outpt private practice settings with pt populations that are stable, I don't know what to say. Really no point in having this argument then.

 

[vistaril]

Low overhead and low startup costs *are* a positive. Whether it ultimately results in more or less net income is a separate matter.

I'll rephrase: the presence of low overhead in any field is often associated with low revenue possibilities, which is the negative. That huge money optho groups spend on surgery centers results in even bigger revenue in return. Always better to spend 100 dollars to make 400 dollars than spending 5 dollars to make 10.

 

[SteinUmStein]

I'll rephrase: the presence of low overhead in any field is often associated with low revenue possibilities, which is the negative. That huge money optho groups spend on surgery centers results in even bigger revenue in return. Always better to spend 100 dollars to make 400 dollars than spending 5 dollars to make 10.

Any data to support that claim? I guess we can go back and forth with conjecture but I'm not sure how useful it is. Also would appreciate the sources you use for your frequent reference to psychiatry as the least respected and least paid specialty, I think it would prove interesting for all of us to see where you're getting your information. Merely repeating something does not make it so.

 

[Ceke2002]

Oh no problem, it's my fault - your location is clearly marked on the left. I just read your post thinking:

ROTFL

Yeah it was kind of like the entire Mental Health system had got their hands on a working TARDIS and decided to travel back to some point in the middle ages. I'm surprised diagnosing by humours, and bloodletting weren't set to make an epic come back.

 

[digitlnoize]

I'll rephrase: the presence of low overhead in any field is often associated with low revenue possibilities, which is the negative. That huge money optho groups spend on surgery centers results in even bigger revenue in return. Always better to spend 100 dollars to make 400 dollars than spending 5 dollars to make 10.

This is hilarious. If you calculate overhead as a percentage of revenue, then your first example (spending $100 to make $400) is 25% overhead! and your second is 50% overhead.

Guess which one is psych and which one is ophthalmology...

Psychiatry overhead is around 25%, this has been discussed ad nauseum on this board. What about ophtho overhead? It's around 60%. Source: http://www.aao.org/publications/eyenet/200807/practice_perf.cfm

You're right. It IS better to spend $100 to make $400...that's why psychiatry rules. It's the only field left in medicine where this is possible.

 

[vistaril]

This is hilarious. If you calculate overhead as a percentage of revenue, then your first example (spending $100 to make $400) is 25% overhead! and your second is 50% overhead.

Guess which one is psych and which one is ophthalmology...

Psychiatry overhead is around 25%, this has been discussed ad nauseum on this board. What about ophtho overhead? It's around 60%. Source: http://www.aao.org/publications/eyenet/200807/practice_perf.cfm

You're right. It IS better to spend $100 to make $400...that's why psychiatry rules. It's the only field left in medicine where this is possible.

generating a relatively small amount of revenue on 25% overhead is far inferior to generating much much much larger revenue on 50-60% overhead.....

You know what has an even lower overhead than 25%? Setting up a lemonade stand....you can do it for a dollar a day, and if one really works at it I bet you could make 10-15 bucks. That's less than 10% overhead!!

Things like building surgery centers cost money. They generate that money back....and then some. That's why those guys have multiple beach houses.

 

[digitlnoize]

generating a relatively small amount of revenue on 25% overhead is far inferior to generating much much much larger revenue on 50-60% overhead.....

You know what has an even lower overhead than 25%? Setting up a lemonade stand....you can do it for a dollar a day, and if one really works at it I bet you could make 10-15 bucks. That's less than 10% overhead!!

Things like building surgery centers cost money. They generate that money back....and then some. That's why those guys have multiple beach houses.

You really don't understand business, do you?

You're right. Surgeons make infinite money and we don't. We're quite inferior to them in every way actually.

I'll take my lemonade stand and see you at the beach.