Perspective from attendings on shaping your careers? Words of wisdom?

[Doctor Bagel]

So I delayed adulthood a little by doing a fellowship and am now trying to figure out what my future will look like afterwards and am feeling a mix of stress, anxiety, discouragement, excitement -- you know. I think ultimately I want flexibility and by flexibility I think that means I want the ability to start some sort of practice. As I'm not wealthy and have a ton of student loans, I'd also like some guaranteed income in there somewhere. Right now I'm leaning toward various things like taking a part-time community MH type of job, doing on call work at local hospitals, locus (? huge unknown), and I'm wondering about people who've followed similar paths and what your experiences have been. Ideally I'd like to have at least one free day to start a practice but am wondering how to put that all together.

I think some of you out there have followed similar paths, and I was wondering about your experiences, thoughts, advice.

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[vistaril]

So I delayed adulthood a little by doing a fellowship and am now trying to figure out what my future will look like afterwards and am feeling a mix of stress, anxiety, discouragement, excitement -- you know. I think ultimately I want flexibility and by flexibility I think that means I want the ability to start some sort of practice. As I'm not wealthy and have a ton of student loans, I'd also like some guaranteed income in there somewhere. Right now I'm leaning toward various things like taking a part-time community MH type of job, doing on call work at local hospitals, locus (? huge unknown), and I'm wondering about people who've followed similar paths and what your experiences have been. Ideally I'd like to have at least one free day to start a practice but am wondering how to put that all together.

I think some of you out there have followed similar paths, and I was wondering about your experiences, thoughts, advice.

DB, we're not dealing with a complicated Chinese menu here- the choices are pretty much laid out in front of you and you already know what they are. We get it you're looking for a nice guaranteed salary while you try to build your own private practice. So as you said, pick a job that is 25-32 hours per week(community mental health is a possibility as is just doing outpt work for another practice- shouldn't be that hard to find). Another way to get this number of hours is to go through a locums agency and if your area is big enough I bet there are a few locums outpt jobs right now that would allow you to work those hours and have some flexibility in it. There is nothing magical about most locums work in psych- it's not truly locums. Most of it is actually just longterm gigs that they haven't filled so they fill them in 3 and 6 month 'locums' cycles. They end up paying more per hour(after the locums company) but they gain added flexibility and no benefits.

The 'on call' work at local hospitals is a bit vague and Im not sure what you mean by that. Most 'on call' work in hospital systems for psych(besides weekend rounding which is sometimes contracted out, but that's not just being on call that's actually being the weekend in house person to sign charts and round and do admissions) is home/phone and it's often rotated amongst the normal staff(sometimes compensated extra nominally). This is not revenue generating and seeing as how it is not revenue generating there isn't going to be any need for them to hire someone part time to do it.

 

[Doctor Bagel]

DB, we're not dealing with a complicated Chinese menu here- the choices are pretty much laid out in front of you and you already know what they are. We get it you're looking for a nice guaranteed salary while you try to build your own private practice. So as you said, pick a job that is 25-32 hours per week(community mental health is a possibility as is just doing outpt work for another practice- shouldn't be that hard to find). Another way to get this number of hours is to go through a locums agency and if your area is big enough I bet there are a few locums outpt jobs right now that would allow you to work those hours and have some flexibility in it. There is nothing magical about most locums work in psych- it's not truly locums. Most of it is actually just longterm gigs that they haven't filled so they fill them in 3 and 6 month 'locums' cycles. They end up paying more per hour(after the locums company) but they gain added flexibility and no benefits.

The 'on call' work at local hospitals is a bit vague and Im not sure what you mean by that. Most 'on call' work in hospital systems for psych(besides weekend rounding which is sometimes contracted out, but that's not just being on call that's actually being the weekend in house person to sign charts and round and do admissions) is home/phone and it's often rotated amongst the normal staff(sometimes compensated extra nominally). This is not revenue generating and seeing as how it is not revenue generating there isn't going to be any need for them to hire someone part time to do it.

By on-call, I mean I've seen a few openings for nearby hospitals that are specifically listed as on-call positions, which I think means weekends/evenings and probably irregular work schedules. Kind of like moonlighting types of positions although they don't generally hire non-BE people.

I guess locums seems like the biggest uncertainty just because I don't know many people who've done locums work. I'm wondering if it's likely that the jobs are especially miserable, which is why they can't be filled. I guess on that note, what have been your experiences with code words for miserable? Also, when cobbling things together, how many things turn into too many things?

 

[smalltownpsych]

By on-call, I mean I've seen a few openings for nearby hospitals that are specifically listed as on-call positions, which I think means weekends/evenings and probably irregular work schedules. Kind of like moonlighting types of positions although they don't generally hire non-BE people.

I guess locums seems like the biggest uncertainty just because I don't know many people who've done locums work. I'm wondering if it's likely that the jobs are especially miserable, which is why they can't be filled. I guess on that note, what have been your experiences with code words for miserable? Also, when cobbling things together, how many things turn into too many things?

In this field, my experience has been that we always end up with more work than we anticipated so keep that in mind when adding things up. That 25-32 hour CMH job is going to look more like 35, if not 40 hours. Also, the learning curve affects how much we can do. I can manage a lot more patients when I know the system well because some of the tasks have become automatic whereas when I am new, I get lost on the way to the coffee machine.

 

[vistaril]

By on-call, I mean I've seen a few openings for nearby hospitals that are specifically listed as on-call positions, which I think means weekends/evenings and probably irregular work schedules. Kind of like moonlighting types of positions although they don't generally hire non-BE people.

I guess locums seems like the biggest uncertainty just because I don't know many people who've done locums work. I'm wondering if it's likely that the jobs are especially miserable, which is why they can't be filled. I guess on that note, what have been your experiences with code words for miserable? Also, when cobbling things together, how many things turn into too many things?

the thing about working in person weekends/evenings at psych hospitals is that you only get reimbursed for ONE admission. The night person can't admit the patient and get reimbursed for that code and then the regular day person do it as well and get the same code. So that's why when patients come in over the evening or night someone with admitting privledges at that site just admits the person over the phone, and then the next morning the regular psych for that team does the whole normal thing and bills for it. If a group or individual practitioners want to have a guy getting reimbursed for those evening and night admissions, that's fine and all but more money doesn't just materialize out of thin air to pay the extra guy. What I'm saying is that in inpatient community psychiatry there is a fixed pot of money for that admission and however many days. If you bring in people at night and on the evenings in person to bill for some of that, the pot shrinks and the primary inpatient team loses out on a bunch of cash.

What I would guess these 'on call' positions consist of is weekends where you are paid a flat sum(and they collect on the billing codes you submit for admissions and f/us) and then any overflow as well(again flat sum and then they collect on the overflow codes).

Again, as with everything always look for where the money is coming from/how the money to pay you is generated. That's what it all boils down to. Not enough residents and people just out of residency focus on that question- what is generating the money(!), where is it coming from and what am I doing to protect my share. I know people out a few years now who graduated before me who still don't get this concept.

As for locums, like I said I wouldn't even look at most of those jobs as locums. True locums is- "so and so went into labor early and we need someone to cover for her until she gets back". This could be a person salaried in a hospital system or her arranging her own coverage for her private practice. Those will *not* be most of your locums jobs in psychiatry. Most of the jobs are going to be long term locums- and how much do they suck? Well just like with non locums jobs it depends on the job. Some are ok and some are terrible. Arent you on job boards now? I probably get 15 of these perm to long term locums mailings daily....once you see a few and talk to them(or do a couple) you start to get a sense of what they're about. I wouldn't worry about it- some of the outpt 25-30 hrs a week community mental health jobs are going to go through agencies to try to fill the position for 3+ months(thus making them a 'locums' job) and some won't- but the jobs may be exactly the same. So unless it's true locums work, don't get hung up ont he differences....

 

[vistaril]

In this field, my experience has been that we always end up with more work than we anticipated so keep that in mind when adding things up. That 25-32 hour CMH job is going to look more like 35, if not 40 hours. Also, the learning curve affects how much we can do. I can manage a lot more patients when I know the system well because some of the tasks have become automatic whereas when I am new, I get lost on the way to the coffee machine.

trust me, in a true locums position that cmh job is going to *make sure* the psychiatrist works as closely to the agreed upon hours as possible because once the clock starts running over that starts to get very expensive for them.

 

[Doctor Bagel]

trust me, in a true locums position that cmh job is going to *make sure* the psychiatrist works as closely to the agreed upon hours as possible because once the clock starts running over that starts to get very expensive for them.

But is there an expectation when the clock runs over that you don't bill for it? The clock often runs over because of things like documentation and not direct patient care.

 

[vistaril]

But is there an expectation when the clock runs over that you don't bill for it? The clock often runs over because of things like documentation and not direct patient care.

heck no you shouldn't be doing documentation and charting in time that is unbilled on a locums job. That's the most insane thing I've ever heard. Obviously you want to discuss this sort of stuff before you start, and by discuss it I mean make sure your patient load is such that you have time to chart in between patients. Note that they aren't going to want to be paying you to sit around for an hour and work on 'paperwork' after your done, so you're definitely going to want to do all this stuff as the day goes by.

Bottom line though db, is that most locums jobs are going to pay you so many set hours to do x amount of work. Usually, you can do x amount of work well within the number of hours they give you. I had one locums job where I get paid for 8.5 hrs each day and sometimes I only work 6.5. I still get the 8.5 hours. I'm not crazy enough to put 6.5 on the time sheet.

So most likely they are going to pay you 8 hours at a certain rate. You're really expected to get what they want you to do within that 8 hours, so just make sure you can. And do the charting and stuff as you go.

 

[smalltownpsych]

But is there an expectation when the clock runs over that you don't bill for it? The clock often runs over because of things like documentation and not direct patient care.

Which fits with what Vistaril said about looking at where the money is coming from. Nobody wants to pay us to do paperwork so the better jobs tend to have less onerous paperwork requirements or more support doing it. I use the dictation services of the hospital to do intakes, progress notes, and even the psycho-historical background of my assessment reports and that keeps my non-billable time to a minimum and leaves me a few extra minutes to chat it up on this board or with colleagues.

 

[nitemagi]

1. Make sure your bills are paid
2. Experiment with private practice models (and research it first)
3. Accept credit cards

 

[Doctor Bagel]

Which fits with what Vistaril said about looking at where the money is coming from. Nobody wants to pay us to do paperwork so the better jobs tend to have less onerous paperwork requirements or more support doing it. I use the dictation services of the hospital to do intakes, progress notes, and even the psycho-historical background of my assessment reports and that keeps my non-billable time to a minimum and leaves me a few extra minutes to chat it up on this board or with colleagues.

I guess that's where trainee experiences aren't that helpful because I think most of my work sites have been documentation heavy. Of course chart review in a setting like the VA can take forever if you do it well because there's so much freaking information.

 

[Doctor Bagel]

1. Make sure your bills are paid
2. Experiment with private practice models (and research it first)
3. Accept credit cards

Hmm, credit cards. I guess that's easy enough with phone apps. What makes it better than cash/checks? Easier to track?

 

[nitemagi]

Hmm, credit cards. I guess that's easy enough with phone apps. What makes it better than cash/checks? Easier to track?

Convenience.

And not everyone has the cash available that day for you. Or they forget their checkbook.

 

[Frazier]

Hmm, credit cards. I guess that's easy enough with phone apps. What makes it better than cash/checks? Easier to track?

Less likely to bounce.
Easier collection for no shows.

 

[Armadillos]

Just out of curiosity what % do you end up losing to the processing, etc. for credit cards?

 

[slappy]

Just out of curiosity what % do you end up losing to the processing, etc. for credit cards?

It's usually around 2%, depending on the volume.