Practicing in Missouri

[whopper]

General points.
1) The money is good. There is a lack of psychiatrists here but in places like St. Louis there are enough universities to not feel like you're in that river in the movie Deliverance.
2) Psychiatric infrastructure is incredibly bad.
3) No central pharmacy. We're the only state in the USA without a central pharmacy. Why? Cause this is Murrica and Freedom! (meant sarcastically but this is the reason why).
4) Expect lots of your patients to have guns. Hey it's a red state.
Further details

1) Money: Low property values, low rent, low overhead. This is a very good state for private practice. IT's not a good state for working in the VA, the state or academia because the pay in those places cannot come anywhere near competing with private practice.
Private practices will completely fill up in a matter of 2-3 months. I had about 15% private pay patients from the very beginning with more and more coming in. I have patients literally drive 5 hours to see me.
Money-wise the only bad things are 1-in St. Louis County (and I assume other counties in the state) you have to pay 8.25% (or something like that) of the value of your car in a car tax per year. Yeah I know. I won't buy a new car for this reason despite that my current car is 10 years old cause if I do I'll be paying at least $2000 more a year in taxes.
The other bad things: everything is taxed-even food. Most states argue that since food is necessary it isn't taxed. But in the big scheme of things you still pay less taxes overall vs most other states and hey I buy almost everything online out-of-state for this reason cause that isn't taxed.

2) Infrastructure:
How bad? Aside from the shortage it's so bad that even a terrible psychiatrist will have a full docket of patients. There are clinics here where patients wait 5 hours to see their doctor who is incredibly rude to them and engages in irrational polypharmacy yet these patients have no where else to go.

Patients held in jails that should be found not competent to stand trial wait in jail sometimes even on the order of over a year waiting for a competency evaluation. Yes I know this is unconstitutional but hey it's happening and no one with the power to do so seems to want to fix the problem. (I tried, everyone I turned towards blew me off including the local APA). The people that try to fix it are ignored.

Just as another example, I was the psychiatric director at a county jail. We couldn't send our patients to the hospital even if the person was acutely suicidal unless the patient had an accompanying physical medical problem. If we asked a hospital to take them they'd refuse despite that this is illegal. I reported it to the state medical board and county mental health board and they ignored me. More specifically they told me they sympathized with me, thought I was in the right to be upset, but there was nothing that could be done other than the patient (who is an inmate) suing the hospital. Why this is happening is the county will only reimbuse the hospital if they patient treated is for a physical not but mental illness.

So when suicidal guy bashes his head into the concrete wall and is lying in his own pool of blood then the hospital will agree to take them, but if I have a strong belief he will do it, no they will not take them.

Patients in a short term facility that are not expected to improve or not improve for even months cannot be transferred to a long term facility unless they've been charged with a crime. As a result for patients that are extremely difficult and not expected to make a quick recovery (e.g. TBI patients) some of the hospitals are discharging them knowing full well these patients are still not safe for discharge and writing down things like the patient's unending head bashing to the point of bleeding is from antisocial PD. I'm not kidding and I wish I was.

Due to the lack of infrastructure large metropolitan areas such as St. Louis don't have things like a PES that many metropolitan areas have.

3) No Central Pharmacy:
Yes you heard me right. This is incredibly unwise of the state. This is causing real problems with lack of preventing patients from doctor shopping for controlled substances. As a buprenorphine provider I cannot check a central pharm. It's also having other horrendous effects such as insurance companies refusing to pay for buprenorphine medications because some of them require a central pharm report as part of the prior authorization even when we inform then Missouri is the only state in the nation that doesn't have one. I've had about 3 patients relapse so far because their insurance wouldn't pay for their meds for this very reason.

Why this is going on is because of stereotypical libertarianism/conservativism as dogma instead of really knowing that in this particular manner it doesn't work. Even most libertarians are not absolutists about it and are okay with things like state sponsored vaccinations or mandating weekends off. We have a case here of people who don't understand what is effective vs ineffective inserting dogma into an issue where they don't understand the issue. Specific politicians in the state government will not allow a central pharm for these reasons.

4) Like I said red state. So far it's not been a problem, but I do expect some gun case complication some day in the near future as a result. I'm talking about maybe 10-20% of my patients have guns or are in a household with guns while when I was in NJ I had around 5 total gun owning patients my entire residency.

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[vistaril]

A few points....

1) I have a hard time believing that VA salaries in much of Missouri can't compete with private practice. You a literally talking about 85-120 worth of benefits per year extra in many cases vs true private practice. The vacation and sick days are insane, the 401k is insane(literally over 11 percent of salary per year if you choose it), the cme is great, the incentive bonus is awesome, the health insurance is subsidized to a crazy extent, and on and on. Comparing a 220k offer from the va to a 245k offer from a com unity hospital will lead to a conclusion that the 245k job pays far less. Oh and VA bennies are NOT like bennies from other govt job, be they state or whatever. They are 10x better.

2) why do you think such a low percentage of your patients(both in nj and Missouri) have guns? I've had a number of depressed patients who I turned on to guns, and it's something they really got into and had a lot of enjoyment from. Just a thought.

 

[Trismegistus4]

I've had a number of depressed patients who I turned on to guns, and it's something they really got into and had a lot of enjoyment from. Just a thought.

I'm conservative and believe in the right to own guns, but I LOLed at this. More grade-A trollery right there.

 

[wolfvgang22]

Branson is fun.

 

[vistaril]

I'm conservative and believe in the right to own guns, but I LOLed at this. More grade-A trollery right there.

Perhaps you should try it....in certain patients it has helped a hell of a lot more than brintellix or whatever else garbage the pharm companies are pushing these days. Hobbies and interests are good things for our mood disorder patients.

 

[MLT2MT2DO]

#3 Are you referencing PDMP, I haven't heard the phrase "central pharmacy".

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[notdeadyet]

You a literally talking about 85-120 worth of benefits per year extra in many cases vs true private practice.

VA benefits are much better when viewed in theory than in practice. The VA has solid benefits, but it's nothing I'd drool over.

The vacation and sick days are insane, the 401k is insane(literally over 11 percent of salary per year if you choose it)

You can defer up to $17-$23K of your pre-tax income (depending on age) into their Thrift Savings Plan. This is nice, but I wouldn't qualify it as insane.

The old pension style retirement pension is not what it once was. It's roughly 1% for each year of service. That's certainly nothing to sneeze at, but again, it's less than other jobs.

The VA has nice vacation/sick days, no doubt about it.

the incentive bonus is awesome,

This bonus is highly variable depending on your site. In some places, they only give the incentive bonus to people working at the remote clinic. In other places, they divide it evenly among ALL physicians. So you could get a nice chunk of change for working hard, or you could get nothing for working hard. This shouldn't be counted on.

It's similar to the $120K loan repayment. The program doesn't have funding for everyone, so it's allocated differently at different places. You may or may not be eligible.

the health insurance is subsidized to a crazy extent

Absolutely not true. My health insurance rates went up dramatically to working for the feds as opposed to working for the state. The VA offers a wide variety of healthcare coverage, but your premiums are much higher at the VA than I've seen for other county and state jobs. I actually consider the VA healthcare coverage one of the worst packages I've seen (in terms of cost to employees) amongst the various job offers I looked at.

The rest of the insurance is also not great. The disability insurance isn't sufficient and you'll likely want to supplement it with private.

Comparing a 220k offer from the va to a 245k offer from a com unity hospital will lead to a conclusion that the 245k job pays far less. Oh and VA bennies are NOT like bennies from other govt job, be they state or whatever. They are 10x better.

Ack. This makes me question how much experience you have with federal, state, or county jobs. And more importantly, where.

I know you hate hearing this, but it will vary based on your location. Out my way, working for the state or county has far, far better benefits than working for the VA. This is true for pension, healthcare, disability, and pretty much every benefit (other than matching into TSP, which some counties are more stingy with). VA benefits, for where many of us live, should be viewed as solid, but nothing to write home about.

 

[notdeadyet]

why do you think such a low percentage of your patients(both in nj and Missouri) have guns? I've had a number of depressed patients who I turned on to guns, and it's something they really got into and had a lot of enjoyment from. Just a thought.

Do some more training in risk assessment, and you'll see why this is an incredibly bad idea.

The most common reason psychiatrists are sued is for completed suicides. If you had a patient who came to you for depression that you "turned on to guns" and they subsequently completed a suicide, any forensic psychiatrist worth his salt would provide testimony that could prove very costly to you indeed.

I like a good IPA or stout, myself. But I don't recommend that my depressed patients start drinking either.

 

[vistaril]

VA benefits are much better when viewed in theory than in practice. The VA has solid benefits, but it's nothing I'd drool over.

You can defer up to $17-$23K of your pre-tax income (depending on age) into their Thrift Savings Plan. This is nice, but I wouldn't qualify it as insane.

The old pension style retirement pension is not what it once was. It's roughly 1% for each year of service. That's certainly nothing to sneeze at, but again, it's less than other jobs.
/QUOTE]

No it's not an issue of deferring....you put in 3%(that's what you defer) and then they put in 9.6%....that's just free ****ing money. On a 230k salary that's over 20k. And then there is another broader additional 401k type option as well. In most jobs, you might get matching(which would be 3 percent in this case) and the matching may even be conditional(like it doesn't vest until a couple years). There is nothing 'theory' about that....it is what it is.

Then you mention the old style retirement thing....dude, that's ON TOP of the main thrift plan. ON TOP OFF. That's unheard of.

I've worked jobs in the private sector before. And I've seen the va Bennie numbers. I would rather have a 210k va job than a 285k private job....and that's BEFORE even considering the massive work expectation differences.(literally seeing 2-4x as many patients in the private job)

 

[vistaril]

Do some more training in risk assessment, and you'll see why this is an incredibly bad idea.

The most common reason psychiatrists are sued is for completed suicides. If you had a patient who came to you for depression that you "turned on to guns" and they subsequently completed a suicide, any forensic psychiatrist worth his salt would provide testimony that could prove very costly to you indeed.

And I would tell him to go **** himself and so would any jury. I'm not saying every single mood d/o patient is a great candidate to go out and develop an interest in guns. Safety assessments should be employed. But with patients who are depressed and lack any hobbies or interests, encouraging interests and hobbies are a good thing.

 

[deleted736562]

Thanks whopper for the great insight.

 

[notdeadyet]

No it's not an issue of deferring....you put in 3%(that's what you defer) and then they put in 9.6%....that's just free ****ing money.

Your math is off. For the Thrift Savings Plan, it works out to be that you can defer 5% of your salary with the government matching 5%.

You're right that the government matching 3:1 would be awesome, but they do not. The VA contributes 1 percent of your wages to the TSP straight up. Then, the VA matches your contributions $1.00 per $1.00 for the first 3 percent of earnings contributed and $.50 per $1.00 for the next 2 percent of earnings. To a total of 5% of your earnings matched by 5% from the VA.

In most jobs, you might get matching(which would be 3 percent in this case) and the matching may even be conditional(like it doesn't vest until a couple years). There is nothing 'theory' about that....it is what it is.

Every state and county job I looked at had matching. Most either matched 1:1 or 0.5:1 up to 6%. So the VA was better, but not impressively so for many off the jobs.

Then you mention the old style retirement thing....dude, that's ON TOP of the main thrift plan. ON TOP OFF. That's unheard of.

A 401K on top of a pension is pretty much the standard for county and state jobs. Very much heard of.

I've worked jobs in the private sector before. And I've seen the va Bennie numbers. I would rather have a 210k va job than a 285k private job....

I agree with you that you need to incorporate benefits into judging financial advantages of one job to the next, but you have to do so sensibly.

A VA job that pays $210K VA job will have you put $10,500 of your own money into the TSP. That $10,500 will be matched 1:1. You will have a rough income now of $200K for $21K in deferred retirement money. That's nice, but most folks could make a better retirement out of the extra $85K the second job would allow for retirement and make it work a lot better than the $21K you deferred.

To each their own. VA has nice benefits, but they aren't amazing. If you really feel like they are, it's a reflection of the jobs you're comparing them to. And based on your posting on this site, you obviously have a lot more limitations than most of us in terms of jobs you are looking at.

 

[notdeadyet]

And I would tell him to go **** himself and so would any jury.

You are what the plaintiff's attorney refers to as "lunch."

I'm not saying every single mood d/o patient is a great candidate to go out and develop an interest in guns. Safety assessments should be employed. But with patients who are depressed and lack any hobbies or interests, encouraging interests and hobbies are a good thing.

Yes, if a patient is so depressed that they lack any hobbies or interests, encouraging them to develop interests and hobbies is a great plan. But encouraging this patient to choose the only hobby that includes spending time with the most commonly used lethal means of suicide is just showing no common sense.

Recommending guns to a depressed patient with no hobbies or interests shows either you're not employing the "safety assessments" you're talking about or you aren't doing them properly.

 

[vistaril]

Your math is off. For the Thrift Savings Plan, it works out to be that you can defer 5% of your salary with the government matching 5%.
QUOTE]

I've seen the papers of jobs people I know work at va and the numbers are what I said.

Plus there is this Below I was given. Note the section on retirement. It doesn't look like your va info is up to date or accurate.

Hear from a current VA Psychiatrist on why you should consider VA... "I still love being a psychiatrist at the VA after 10 years . Compared to my community work, all my patients are eligible for medication, labs and medical care. Managed care is not a problem and I no longer have concerns about malpractice issues since the government provides coverage and this discourages lawsuits without merit. We have cutting edge technology including the new CVT to home. The VA has innovative programs in prevention, home based primary care, palliative care and Integrated care. Veteran centered care is a priority as opposed to profits.


More great facts about VA!

• No physician employment contracts-thus no restrictions on working in multiple places
• Paid malpractice and tail coverage
• Work with 1 current, unrestricted license in any US state or territory
• Exceptional student loan repayment options
• Federal benefits-government covers large portion allowing you to take home more of your earnings
• Recruitment and or Relocation incentives may be offered to highly qualified candidates
• EMR available (VA was pioneer in establishing electronic medical record!)

Work Schedule: Several options available. Salaries recently increased in this specialty-incentives offered-bonus potential-excellent work/life balance! Whether you’re interested in academics, research, or a better work/life balance, you’ll find the VA has a lot to offer, including the unmatched satisfaction you’ll get from caring for those who have served our country.


In addition to competitive pay and liability protection, the VA also offers a robust benefits plan that includes: Paid Time Off: 26 Days paid annual (vacation/personal) leave –you can carry over up to 86 days into a new year 13 Days paid sick leave each year with no limit on accumulation – unused sick leave can be used to extend creditable service time at retirement! 10Federal holidays per year with pay 5 Days paid absence to attend approved CME courses(subject to budget availability)


Insurance: Health Insurance: VA employees have an outstanding number of health insurance plans from which to choose (premiums are partially paid by VA) Dental & Vision: Our insurance options also include exceptional vision and dental plans (premiums are partially paid by VA). VA employees have the option to use Flexible Spending Accounts, which allow you to use tax-free dollars to pay for medical, dental, and vision care expenses that are not reimbursed by your health insurance plan. Term life insurance, family, and additional coverage options are available with the cost shared by the Federal Government. Long-term care insurance is available as an option.


Federal Retirement Plan: VA employees are covered by the Federal Employees Retirement System (FERS).FERS is a three-tiered retirement plan composed of 1) Social Security benefits; 2) FERS basic benefits (pension); and 3) Thrift Savings Plan (TSP) which is a 401K-type plan How is the pension funded? VA employees automatically contribute 3.1% of their salary each pay period and the VA contributes9.6% of the employee’s salary each pay period for a total annual contribution percentage equal to 12.7% of the employee’s salary Similar to the 401(k) savings plans widely available in the private sector, the TSP allows employees to tax defer a portion of their income each year, subject to the requirements of the Internal Revenue Service. For calendar year 2013, employees under the age of 50 may contribute up to $17,500,while those over age 50 are eligible to make catch-up contributions that allow them to defer up to $23,000. The Federal Government also provides an automatic basic contribution (1% of salary) and up to 4% of salary in matching contributions, depending on the amount of the employee contribution. For retired military personnel, these benefits are in addition to full monthly retirement pay or pension In addition to FERS, VA provides health care insurance coverage for retired personnel Disability Retirement Employees are vested in a federal pension after only 5 years’ service.


Send your CV today to receive consideration!

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Department of Veteran Affairs 1601 Cloverfield Blvd #3050N Santa Monica, CA 90404

 

[nexus73]

Missouri sounds like Idaho with fewer potatoes.

 

[masterofmonkeys]

I'm an NRA life member and even I don't do that lol

 

[vistaril]

You are what the plaintiff's attorney refers to as "lunch."

Eh....Never been sued before. I don't think you have a good understanding of liability in psychiatric practice, especially in terms of the situations in which judgments come about from self harm cases or cases where our patients hurt others. They tend to cluster in very specific situations and settings(not chronic outpts who are deemed stable enough to own firearms)

 

[birchswing]

I'll play the straight foil: Assume that a patient going to the gun range works. What is the chance that any person, depressed or not, continues that particular hobby for a lifetime? What is the recurrence rate of MDD? If this gun range therapy doesn't work for a lifetime and the patient's depression returns, you now have a depressed patient with a gun in their house. I think any other hobby than one that involves owning firearms is probably a good idea for a depressed person. In fact, I can't think of a hobby that could have as many risks as one involving owning a gun.

 

[notdeadyet]

I've seen the papers of jobs people I know work at va and the numbers are what I said.

Your second hand information you're relying on for your figures is either flat out incorrect or you're misinterpreting them. See below.

Plus there is this Below I was given. Note the section on retirement. It doesn't look like your va info is up to date or accurate. <snip>

The below that you pasted is the boilerplate for VA job ads you'll see all over the web.

If you read the section on the Retirement Plan, you'll see it talks about FERS, made up of three components. Social Security (which I think we all understand), the pension, and the TSP (the 401K-like animal). The 3.1% employee contribution and VA 9.6% contribution you're referring to is not a fourth benefit; it's an explanation of how the pension component is funded. It means that the 1% or 1.1% per year worked pension you can receive when you retire is funded in part by your employee contribution of 3.1% of your salary that you pay in plus the VA's contribution.

Keep reading what you posted and you will see that the TSP includes employee contributions of up to $17K until age 50 or $23K after age 50. It also includes government matching of 5%. These are the figures I referred to above.

In short: the VA has good benefits. Better than state or county jobs? Depends on the state or county jobs, apparently. Maybe it does out your way, but out mine, you'll get better salary and pension from state jobs, but worse vacation at most of them as compared to the VA. The county jobs are mostly similar pay, better pension, worse vacation.

 

[whopper]

1) I have a hard time believing that VA salaries in much of Missouri can't compete with private practice. You a literally talking about 85-120 worth of benefits per year extra in many cases vs true private practice. The vacation and sick days are insane, the 401k is insane(literally over 11 percent of salary per year if you choose it), the cme is great, the incentive bonus is awesome, the health insurance is subsidized to a crazy extent, and on and on. Comparing a 220k offer from the va to a 245k offer from a com unity hospital will lead to a conclusion that the 245k job pays far less. Oh and VA bennies are NOT like bennies from other govt job, be they state or whatever. They are 10x better.

In Vistaril's defense (and I'm surprised I'm saying this) one could have a very different opinion of the benefits.
Also, for me, I don't need any job benefits cause my wife gives them to me through her job. Egocentric of me to not factor this in and mention this. So for me there is almost no point of benefits except for the retirement package.

 

[notdeadyet]

Eh....Never been sued before. I don't think you have a good understanding of liability in psychiatric practice, especially in terms of the situations in which judgments come about from self harm cases or cases where our patients hurt others.

I did a forensic fellowship and have watched, worked on, or testified in cases like these. You should check them out. It's educational.

You can encourage every patient you ever have to go out and buy guns and shoot them daily and not have a single patient suicide. Suicide is a (thankfully) relatively rare event. But if you do have a patient who kills himself with a means that you recommended to him while you were treating him while he was suffering from depression and lacking in hobbies or interest, you will not look good in court. Specifically recommending the most common means for completed suicide to a patient currently exhibiting a serious modifiable risk factor for suicide (current depression) indicates that you did not conduct an adequate risk assessment and it would not be hard to argue that you operated below the standard of care, and that your doing so directly led to the patient's suicide.

Who knows what might happen in court? But I wouldn't want to be you on the stand in this case.

They tend to cluster in very specific situations and settings(not chronic outpts who are deemed stable enough to own firearms)

I don't know of any states in which chronic outpatients need to be deemed stable enough to own firearms. And given the region you live in, I doubt very much your state has laws that require demonstration of stability to own a firearm.. Your patients by default are deemed by the law to be stable enough to own firearms until the state determines otherwise (through involuntary inpatient admission or a few other way).

 

[notdeadyet]

In Vistaril's defense (and I'm surprised I'm saying this) one could have a very different opinion of the benefits.

Yup, my point exactly. How good benefits are is a very user dependent. VA benefits are probably the holy grail if you live in an area in which no one offers any kind of retirement plan. They are rightfully seen as terrible when everyone else is offering better retirements and pensions.

It's the superlatives I disagree with. The VA isn't setting the bar on this stuff. Their benefits (particularly retirement) used to be a lot better than they are currently, so I think sometimes people have outdated impressions about how good they are. The math doesn't (or no longer) bears that out.

I think I just have a sore spot when it comes to folks over-hyping VA, state, and county gigs in terms of cush-ness/benefits. Because I like working in these environments. And you always see the folks that were lured in by those (often false) cush-ness/benefits descriptions. And then everyone is stuck working with the person who whines and complains when the work gets hard or gripes about the fact that the benefits aren't what they thought/were told/assumed. But point taken. I'll sign off on this one.

 

[MacDonaldTriad]

The most common reason psychiatrists are sued is for completed suicides.

I thought it was for boundary violations.

 

[Blitz2006]

How much do psychiatrists pay in malpractice in MO on average ?

 

[notdeadyet]

I thought it was for boundary violations.

Unless my memory fails me (always a risk), suicide is the most common cause for lawsuits against psychiatrists. Boundary violations is the most common cause for successful lawsuits against psychiatrists.

 

[notdeadyet]

I'd also be curious what sort of due diligence you do with patients, lacking what you're calling a Central Pharmacy? When I've needed to contact pharmacies, I've been quite surprised how even some of the larger chains don't have a centralized database (i.e. I needed to call each pharmacy). I'm curious what sort of efforts you go to in MO, given this?

 

[Blitz2006]

We were told last year in lecture that historically it was boundary violations, but recently it is medical reasons (ie. Drug side effects) for #1 reason for lawsuits

Food for thought. My CL attending told me that 20% of people that committ suicide, their families in America file a lawsuit. Of those 20%, only 10% are won by the family.

No idea if this is true, but that's what he told me.

Sent from my SM-N910V using Tapatalk

 

[whopper]

Wanted to clarify a point. Many of you know I was in academia and wasn't planning on leaving but left for private practice. A lot of it had to do with the market forces in this state. The money was too good. In Cincinnati private practice didn't make as much money and the shortage of psychiatrist was no where on the order here.
The practice in a hospital I found too risky and I'm a guy who ran forensic units full of repeat rapists, antisocials, and NGRI people who killed. Why? It was inevitable to get someone in need of long-term care that we could not send to long term. As any of you on an inpatient unit know this will happen on the order of every few days to weeks. To see these people not get the care they needed due to a backwards system was upsetting me daily while I knew I could just walk away and make a lot more money in private practice.
As for my job the academic place had me at most of the time, as I said above, I felt like I was playing Russian Roulette. I did not feel the care was to the standard. We couldn't get patients to a hospital despite that this is illegal. I also had a specific case that I was confident would end in suicide without me being able to send the guy to the hospital and the guy was refusing meds. (You can't force meds in a jail, it's unconstitutional). I pretty much knew the guy would likely be dead in a few weeks to months and despite all of my pleas to the higher ups nothing was being done.
I love teaching but the academic place I was at was cutting my exposure to students and residents more and more so the love factor was slowly being widdled away from me. My position as clerkship director was being reduced to me not being able to see, and in person teach students but simply be at academic meetings where deans talked about varying equations I never heard about that measure student performance while I sat in a daze.
Why suffer through that when there's a nice job that makes about 100% more with less hours and less stress? My work week went from about 65 hours a week to 40 after the job change.

 

[notdeadyet]

Sounds like you made the right call, whopper...

 

[OldPsychDoc]

Eh....Never been sued yet. ....

Fixed it for ya.

 

[masterofmonkeys]

I did the last two years of my residency in Kansas City. Which is also in Missouri, not Kansas, and it was somewhat different than Whopper's experience. First, KC is an awesome town that is both small enough not to be obnoxious but big enough to have an awesome culture. Great museums, including a darn near world class art museum. Good artisan and local-owned shops. Multiple walkable parts of town with a lot of charm. Good housing prices. Reasonable schools.

1) Money. The CMHCs in KC actually pay pretty well. 200k or more typically. Some are low key with 30 minute appointments and a no show rate that makes it even more low key. Others are 15 minute mills though. VA was 220-230k per year from what I remember. Two residencies in the area. One had a sizable research program.

2) Infrastructure. Wait times to get into see a psychiatrist in kansas city were not that bad, especially if you were either uninsured or had medicaid. One month or less. They were actually much longer if you had insurance.

The forensic situation is about as bad as Whopper paints, as far as incompetent to stand trial. We regularly had inmates on our units though.

3) The lack of PDMP was as frustrating as Whopper points out, but the problem was far more bipartisan in origin.

 

[whopper]

Wanted to add MOM
The community hospital situation is actually decent. A resident that recently graduated was offered a job at $260K almost immediately after graduation. I didn't add this.
Again this is because of the lack of psychiatrists. I know a community hospital that will pay $300/hr and wants full-time.
A reason why I didn't do community hospital is because I can't send people to long-term units-something which is inevitable and common. So I knew I wouldn't be doing practice that I respected. Wouldn't have been because of me but because of the state. Further because of this phenomenon ECT is done a heck of a lot more here than I've seen in other places. In fact it's done so much more that I've seen it inappropriately done too soon too often based on my opinion (e.g. offered first or second line. I'm not kidding).

And ECT as all of you know will likely not help someone with mental illness due to TBI and when you get a patient like that and you can't send them to the long-term unit, a short term unit either has to swallow the medicine and keep the guy for months or discharge him knowing full well he's still dangerous. I've seen places do that all too often. As I said it's horrendous and I did complain about it to various state agencies and the APA. I kept getting answers back such as "we know," and "nothing will be done about it cause we too complained up." Again this is because of the local politicians.

 

[nexus73]

Wanted to add MOM
The community hospital situation is actually decent. A resident that recently graduated was offered a job at $260K almost immediately after graduation. I didn't add this.
Again this is because of the lack of psychiatrists. I know a community hospital that will pay $300/hr and wants full-time.
A reason why I didn't do community hospital is because I can't send people to long-term units-something which is inevitable and common. So I knew I wouldn't be doing practice that I respected. Wouldn't have been because of me but because of the state. Further because of this phenomenon ECT is done a heck of a lot more here than I've seen in other places. In fact it's done so much more that I've seen it inappropriately done too soon too often based on my opinion (e.g. offered first or second line. I'm not kidding).

And ECT as all of you know will likely not help someone with mental illness due to TBI and when you get a patient like that and you can't send them to the long-term unit, a short term unit either has to swallow the medicine and keep the guy for months or discharge him knowing full well he's still dangerous. I've seen places do that all too often. As I said it's horrendous and I did complain about it to various state agencies and the APA. I kept getting answers back such as "we know," and "nothing will be done about it cause we too complained up." Again this is because of the local politicians.

No state psych hospitals in Missouri?

 

[whopper]

There are but the state slashed the budget so much and allowed this farcical situation where no one patient would be taken unless they committed a crime. I figure this is going on in other states as well but in NJ and Ohio I saw nothing of the sort. In fact I'd say the situation in Ohio was quite impressive all things considered with the level of organization they had for long-term patients.

 

[nexus73]

There are but the state slashed the budget so much and allowed this farcical situation where no one patient would be taken unless they committed a crime. I figure this is going on in other states as well but in NJ and Ohio I saw nothing of the sort. In fact I'd say the situation in Ohio was quite impressive all things considered with the level of organization they had for long-term patients.

Oregon is another interesting one, where I believe 85-90% of the state hospital beds are occupied by insanity acquittees or competency restoration patients. Leaving hardly any beds for the severely mentally ill with no criminal system involvement.

 

[notdeadyet]

Oregon is another interesting one, where I believe 85-90% of the state hospital beds are occupied by insanity acquittees or competency restoration patients.

Add California, then.

But I wonder the opposite: since the deinstitutionalization movement, are there any/many states in which the state hospital system ISN'T down to about 10-15% non-criminal justice? My experience esst of the Rockies is lacking. Maybe it's a brighter picture out yonder.

 

[Salpingo]

Great idea for a thread! It'd be nice to get a program interview review-style thread for the different states of the Union. Clearly, even within the state the experience varies, but ease of private practice, long term care resources, state involvement in mental health are all fairly objective measures.

Eh....Never been sued before. I don't think you have a good understanding of liability in psychiatric practice, especially in terms of the situations in which judgments come about from self harm cases or cases where our patients hurt others. They tend to cluster in very specific situations and settings(not chronic outpts who are deemed stable enough to own firearms)

I understand this is trolling to bring up the gun issue, but this actually a useful tip that I've received: if you walk into a deposition with the mentality "who are these jerks to tell me how to practice medicine... I'm the one who went to med school, I'm the one that did residency, I've been doing this for x years!", you have already lost, and the trial hasn't even started. As NDY pointed out, that is the bread and butter work for a malpractice lawyer, the equivalent treatment of uncomplicated MDD or GAD: taking apart over confident, egomaniacs. I'm also guessing that's part of the reason neurosurgeons get killed when it comes to malpractice stats (and I'm only half joking)

 

[Ceke2002]

Do some more training in risk assessment, and you'll see why this is an incredibly bad idea.

The most common reason psychiatrists are sued is for completed suicides. If you had a patient who came to you for depression that you "turned on to guns" and they subsequently completed a suicide, any forensic psychiatrist worth his salt would provide testimony that could prove very costly to you indeed.

I like a good IPA or stout, myself. But I don't recommend that my depressed patients start drinking either.

But guns are awesome, they're like high charged pill dispensers filled with little cartridges of happiness. The best thing my super depressed, and unstable friend ever did was join a gun range. The fact that she aimed the gun at her head instead of the actual target is totally besides the point.

 

[zyxab]

Don't you worry about tornadoes? It'd be hard for me to sleep in such a location.

 

[erg923]

Don't you worry about tornadoes? It'd be hard for me to sleep in such a location.

Don't you worry about being run over by a car in the parking lot of your work?

 

[zyxab]

Don't you worry about being run over by a car in the parking lot of your work?

Statistically that is probably far more likely *for the average person*. But for someone who is extremely careful around cars (e.g. always looking both ways when crossing, staying on the sidewalk when in doubt), I suspect dying in a tornado is more likely. Tornadoes are far more unpredictable and destructive than cars.

 

[OldPsychDoc]

Statistically that is probably far more likely *for the average person*. But for someone who is extremely careful around cars (e.g. always looking both ways when crossing, staying on the sidewalk when in doubt), I suspect dying in a tornado is more likely. Tornadoes are far more unpredictable and powerful than cars.

More powerful, yes--but those of us who live in the Midwest generally know the probabilities and keep an ear on the radio when major weather fronts are approaching. Predictability with these thing is much better than that of knowing which random teenage driver in the mall parking lot is going to check her texts the second I step off the curb.

And how's that earthquake prediction thing going, my West coast friends?

 

[erg923]

I suspect dying in a tornado is more likely. Tornadoes are far more unpredictable and destructive than cars.

FALSE

 

[MacDonaldTriad]

The possibility of spontaneous combustion keeps me up. We are exothermic and flammable by the way.

 

[zyxab]

More powerful, yes--but those of us who live in the Midwest generally know the probabilities and keep an ear on the radio when major weather fronts are approaching. Predictability with these thing is much better than that of knowing which random teenage driver in the mall parking lot is going to check her texts the second I step off the curb.

And how's that earthquake prediction thing going, my West coast friends?

I'd be scared of a tornado striking while I'm sleeping though.

 

[birchswing]

I used to be worried about the sudden disappearance of gravity, especially when in large open fields with no trees around. I would suddenly have the thought, "Have scientists determined gravity to be a force in effect in perpetuity?" Terrifying thought to have on a soccer field.

 

[OldPsychDoc]

I'd be scared of a tornado striking while I'm sleeping though.

You can actually set your smart phone to alarm for US Weather Service alerts. http://www.nws.noaa.gov/com/weatherreadynation/wea.html

--Kid traumatized by the Wizard of Oz who is now likely to be the man standing on the front porch recording the dang thing...

 

[whopper]

I'd also be curious what sort of due diligence you do with patients, lacking what you're calling a Central Pharmacy? When I've needed to contact pharmacies, I've been quite surprised how even some of the larger chains don't have a centralized database (i.e. I needed to call each pharmacy). I'm curious what sort of efforts you go to in MO, given this?

I'm not in California but in Ohio to access the Central Pharmacy you simply just apply for access. It involves you paying something like $20, you send them a copy of your medical license, your driver's license and then they give you online access just a few days later. I'm sure each state has different ways of accessing the central pharm.

and as mentioned being that St. Louis has no central pharm it's really annoying the heck out of me when insurance companies are refusing to pay for my patient's meds because I didn't provide them a central pharm report.

Ohio's online central pharm, when I left Ohio, was in the process of linking to the neighboring states such as Kentucky and Indiana. I believe just a few months after I left Ohio Governor Kasich put into law requirements for central pharm access and checks for patients on buprenorphine and I think a few other medications. The central pharm also was of great help to me when seeing patients in the ER.
On one occasion while in the ER, and doing a central pharm check, a nurse who came to the PES told us she was on mega doses of Xanax and Adderall and wanted addiction help fully acknowledging she didn't have ADHD. Thanks to the central pharm it specifically said who the prescriber was. I called his office up to inform them what was going on. (Of course his idiot receptionist wouldn't let me talk to him. I did a google search on the guy. This guy was practicing at about 90 years of age and per the nurse he gave anyone anything they asked for and she knew to go to him cause as a nurse she saw some of this guy's other patients.

One of those things you only figure out with central pharm access.

 

[Doctor Bagel]

Don't you worry about tornadoes? It'd be hard for me to sleep in such a location.

With doppler, they know exactly where those tornadoes are, and the sirens will wake you up. Now earthquakes on the other hand ... No warning, no predictions, no notice. Tornadoes are way less scary.

 

[lymphocyte]

.