Psych hospitalists

[DrAwsome]

Hey psych people, I was talking to a psych friend of mine and we were talking about the whole hospitalist thing that's happening in medicine, and were wondering-how come there are no psych hospitalists in the same fashion that there are IM hospitalists? Seems like it would be a good way to attract psych docs given the shortage. Any input as to why this is not happening yet in psych?

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[digitlnoize]

Hey psych people, I was talking to a psych friend of mine and we were talking about the whole hospitalist thing that's happening in medicine, and were wondering-how come there are no psych hospitalists in the same fashion that there are IM hospitalists? Seems like it would be a good way to attract psych docs given the shortage. Any input as to why this is not happening yet in psych?

How do you mean? Do you mean psychiatrists doing psych consults in the hospital? Or, do you mean psychiatrists who round on patients at psych hospitals?

In either case, I think it's because inpatient psych hours are already not too bad, and even then, it's difficult to attract psychiatrists away from the sweet life that outpatient psych provides. A job would have to pay a pretty penny to get me to work a 12 hour night shift (IM hospitalist style) after I'm done with residency.

 

[DrAwsome]

How do you mean? Do you mean psychiatrists doing psych consults in the hospital? Or, do you mean psychiatrists who round on patients at psych hospitals?

In either case, I think it's because inpatient psych hours are already not too bad, and even then, it's difficult to attract psychiatrists away from the sweet life that outpatient psych provides. A job would have to pay a pretty penny to get me to work a 12 hour night shift (IM hospitalist style) after I'm done with residency.

I mean just like there are IM/neuro hospitalists, that take admissions, consults, round on the patients, etc. What defines "sweet life that outpatient psych provides" exactly? You mean pay wise or hour wise? I was under the impression psych docs are making around 200k. Or is that going up as well?

 

[OldPsychDoc]

We are actually moving more and more to this model. We have 2 of our 5 units staffed by MDs who work "7 on/7 off" like IM hospitalists. Our other units are working on plans to provide 7-day rounding and programming on all patients as well.

 

[vistaril]

Hey psych people, I was talking to a psych friend of mine and we were talking about the whole hospitalist thing that's happening in medicine, and were wondering-how come there are no psych hospitalists in the same fashion that there are IM hospitalists? Seems like it would be a good way to attract psych docs given the shortage. Any input as to why this is not happening yet in psych?

Im not sure I completely understand the question....there are a lot of mostly inpatient psychiatrists who work under a model similar to this.....the difference is that a hospitalist is often 7 on/7 off with 12 hr shifts whereas the psychiatrist is often M-F and has weekends off.

 

[DrAwsome]

Im not sure I completely understand the question....there are a lot of mostly inpatient psychiatrists who work under a model similar to this.....the difference is that a hospitalist is often 7 on/7 off with 12 hr shifts whereas the psychiatrist is often M-F and has weekends off.

Why would IM be 7on 7 off for 12 hr vs. psych M-F 8 hrs/day? That's just sort of like a regular schedule no? Same can be said for IM docs who work M-F with occassional call. But I was asking more about hospitalist type schedules for psychs, which I guess OldPsychDoc is saying they are moving towards.

 

[digitlnoize]

OPD is also in academics which is a totally different beast. The idea of doing 12h, 7 on/7 off shifts in private practice is so abhorrent to me. It's a great life if you're 25 and single. Once you have a family, it becomes pretty silly, since one week you're working a lot and never see your family, then the next week THEY are working (or in school) and you never see them.

Net result = limited family time.

Yes, the average PP salary is in the 180-200k range. The average hours per week is in the 30-40h/wk range though. The guys that are putting in 40-50h/wk are making quite a bit more than average.

 

[DrAwsome]

OPD is also in academics which is a totally different beast. The idea of doing 12h, 7 on/7 off shifts in private practice is so abhorrent to me. It's a great life if you're 25 and single. Once you have a family, it becomes pretty silly, since one week you're working a lot and never see your family, then the next week THEY are working (or in school) and you never see them.

Net result = limited family time.

Yes, the average PP salary is in the 180-200k range. The average hours per week is in the 30-40h/wk range though. The guys that are putting in 40-50h/wk are making quite a bit more than average.

I'm not sure who is 25 and single and working as a hospitalist given that most people are not done with residency until 30 or so, but I get your point. I guess that does make sense though overall and could see your point if you are making around 200k and working 40 or less hours per week. That is a sweet gig! I'm surprised psych is not more competitive.

 

[OldPsychDoc]

OPD is also in academics which is a totally different beast. The idea of doing 12h, 7 on/7 off shifts in private practice is so abhorrent to me. It's a great life if you're 25 and single. Once you have a family, it becomes pretty silly, since one week you're working a lot and never see your family, then the next week THEY are working (or in school) and you never see them.

Net result = limited family time.

Yes, the average PP salary is in the 180-200k range. The average hours per week is in the 30-40h/wk range though. The guys that are putting in 40-50h/wk are making quite a bit more than average.

I'm really not in academics, actually--we're a private non-profit corp with lots of public (i.e. state/county) contracts.

And the psych hospitalists are more of an 8-10 hr day, even in their 7 on, so it's not like they "never" see their families (assuming they want to...)

 

[DrAwsome]

I'm really not in academics, actually--we're a private non-profit corp with lots of public (i.e. state/county) contracts.

And the psych hospitalists are more of an 8-10 hr day, even in their 7 on, so it's not like they "never" see their families (assuming they want to...)

Haha!

 

[digitlnoize]

I'm really not in academics, actually--we're a private non-profit corp with lots of public (i.e. state/county) contracts.

And the psych hospitalists are more of an 8-10 hr day, even in their 7 on, so it's not like they "never" see their families (assuming they want to...)

My bad, aren't you a PD somewhere? Maybe I'm just wrong...or it's a community place...

Anyways, it doesn't sound too bad at all.

 

[OldPsychDoc]

My bad, aren't you a PD somewhere? Maybe I'm just wrong...or it's a community place...

Anyways, it doesn't sound too bad at all.

It's a community place. And a damn fine one, too.

 

[nitemagi]

UCLA-NPI has hospitalists.

 

[twright]

Why would IM be 7on 7 off for 12 hr vs. psych M-F 8 hrs/day? That's just sort of like a regular schedule no? Same can be said for IM docs who work M-F with occassional call. But I was asking more about hospitalist type schedules for psychs, which I guess OldPsychDoc is saying they are moving towards.

I think the difference is that in psychiatry, the 'hospitalist' attending doesn't come in on weekends because psychiatric inpatients are generally not perceived to require the same level of care as medical inpatients. Medicine attendings, even if they are not working along the lines of the hospitalist model, still come in on weekends; they are also typically on call (pager call) during their entire 2-week inpatient block.

At our residency program, the psych attending never came in on weekends -- that position was filled by a weekend rounder attending whose job was basically to eyeball patients, make sure things weren't screwy with their medications, and that was it. No intensive inpatient work. And the psych attending did not take pager call from home -- if we were on call and needed to run something by the attending, even if it concerned one of the active inpatients, we paged the on-call attending whose response was invariably oriented towards putting out the fire and letting the primary team deal with it in the morning.

 

[vistaril]

Why would IM be 7on 7 off for 12 hr vs. psych M-F 8 hrs/day? That's just sort of like a regular schedule no? Same can be said for IM docs who work M-F with occassional call. But I was asking more about hospitalist type schedules for psychs, which I guess OldPsychDoc is saying they are moving towards.

because in the real world in psychiatry, you have 24 hrs to basically do the H&P at most places/systems. If a pt comes into the hospital at 8pm, you'll do the H&P the next morning when you see them.

When pts in medicine get admitted for CHF exacerbations or whatever, obviously it's a different thing.

 

[vistaril]

OPD is also in academics which is a totally different beast. The idea of doing 12h, 7 on/7 off shifts in private practice is so abhorrent to me. It's a great life if you're 25 and single. Once you have a family, it becomes pretty silly, since one week you're working a lot and never see your family, then the next week THEY are working (or in school) and you never see them.

Net result = limited family time.

Yes, the average PP salary is in the 180-200k range. The average hours per week is in the 30-40h/wk range though. The guys that are putting in 40-50h/wk are making quite a bit more than average.

not really true....many salary surverys also track hours, and for psychiatry they are usually given as between 45-48.

A lot of people in other specialties work part time as well. Psychiatry is no different.

psychiatry generally has a higher starting salary floor for new grads than many of the other lower paying fields. But a lower ceiling.

people in every field/forum typically misrepresent their salaries compared to other fields. For example, you have people in psych coming up with ways in psychiatry to make 30% or so more, but then comparing that position to a position in say internal medicine or neurology where the same choice wasn't made.

in general psychiatry can be lumped in, salary wise, with the other lower paying fields(peds, fam med, etc....) I would also include pathology in here because although pathology's average isnt that bad, the opportunities and ranges for new and junior attending pathologists is pretty depressing. Psychiatry, by comparison, has a much more narrow range.

A lot of people in certain specialties can push 7 figures if they really hustle.....psych is obviously not one of these. most psychs would have to really hustle and/or take unfavorable positions to make 1/3 of that.

 

[vistaril]

It's a community place. And a damn fine one, too.

my guess is that a lot of the attendings that work at community programs are pretty decent. The problem in so many cases is that the programs are mostly img with some DO's mixed in.......

i think, in general, if a program has 1-2 total imgs then people will always wonder if maybe those img's were just real superstars. But when a program is 80% img and DO, well some people have a certain opinion on that......not for the skill of the attendings really, but just of the quality of residents they are able to get.

 

[OldPsychDoc]

my guess is that a lot of the attendings that work at community programs are pretty decent. The problem in so many cases is that the programs are mostly img with some DO's mixed in.......

i think, in general, if a program has 1-2 total imgs then people will always wonder if maybe those img's were just real superstars. But when a program is 80% img and DO, well some people have a certain opinion on that......not for the skill of the attendings really, but just of the quality of residents they are able to get.

And some people have shown a remarkable ability to generalize from their own opinions and biases to judge programs and people about which they have no actual knowledge.

 

[digitlnoize]

not really true....many salary surverys also track hours, and for psychiatry they are usually given as between 45-48.

Care to post some links? Most salary surveys do NOT, in fact, track hours by specialty.

The most recent one that DID do so, was the Medscape survey, which showed that well over 50% of psychiatrists worked < 40 hours per week with an average salary around 180-200k. The most popular answer for hours worked per week was < 30.

Please, cite me some surveys that support your assertions. I'd love to see it.

 

[jamesearlejones]

i guess i don't understand this question. what's the difference between a psych "hospitalist" and an inpatient psychiatrist? there are many places where psychiatrists work just on the inpatient unit at a hospital. i'm not sure about the semantics, but wouldn't these folks be considered hospitalists? incidentally, the lifestyle for inpatient positions can be excellent: m-f, 8:30-5:00 with no call, no nights, no holidays or weekends. in fact, i think inpatient psychiatry affords a better lifestyle than a lot of outpatient practices. the hours are more regular and consistent, you can actually spend more time with patients (and families) if you manage your day right, and you're less often having to deal with the hassles of outpatient work (returning millions of voicemails, getting Rxs faxed, getting PAs, etc, etc) just my $0.02

 

[DrAwsome]

Care to post some links? Most salary surveys do NOT, in fact, track hours by specialty.

The most recent one that DID do so, was the Medscape survey, which showed that well over 50% of psychiatrists worked < 40 hours per week with an average salary around 180-200k. The most popular answer for hours worked per week was < 30.

Please, cite me some surveys that support your assertions. I'd love to see it.

I think you are correct.The last medscape survey that I saw also showed the range of hours you mention.

 

[DrAwsome]

i guess i don't understand this question. what's the difference between a psych "hospitalist" and an inpatient psychiatrist? there are many places where psychiatrists work just on the inpatient unit at a hospital. i'm not sure about the semantics, but wouldn't these folks be considered hospitalists? incidentally, the lifestyle for inpatient positions can be excellent: m-f, 8:30-5:00 with no call, no nights, no holidays or weekends. in fact, i think inpatient psychiatry affords a better lifestyle than a lot of outpatient practices. the hours are more regular and consistent, you can actually spend more time with patients (and families) if you manage your day right, and you're less often having to deal with the hassles of outpatient work (returning millions of voicemails, getting Rxs faxed, getting PAs, etc, etc) just my $0.02

I agree that inpatient psychs can have an excellent lifestyle. But that's no different from IM/FP docs who work solely at the hospital too I guess. But the hospitalists work 7 on/7off so I was wondering why psych hospitalists don't work the 7 on/7 off but I guess due to the nature of the work, it's a little different and would be kind of unnecessary.

 

[digitlnoize]

I think you are correct.The last medscape survey that I saw also showed the range of hours you mention.

Yeah, and I don't want vistaril to misunderstand me and think I'm saying that psych = neurosurgery, because it doesn't. He is mostly right in that psych does trend towards being a "lower paying" field, like FM or Peds.

That being said, if your goal is to make good money while still providing good care, it can certainly be done in psych. If your goal is to only make money, you should look at other fields, but that can be done in psych also.

I know pediatricians, psychiatrists, and FM docs clearing over 500k and some over 1 million a year. I think it's possible, but difficult, with good business sense, to clear 500k ethically in psych. Clearing a million is probably ethically suspect, and not something to expect.

I've crunched the numbers a hundred times in a hundred different ways for private practice, and no matter which way you set up your office, if you're working a full work week, with one mid-level extender, seeing at least 3-4 patients per hour, there is plenty of potential for a very nice income and provide good care, without having to stoop to being a pill mill.

 

[pipe dream]

my guess is that a lot of the attendings that work at community programs are pretty decent. The problem in so many cases is that the programs are mostly img with some DO's mixed in.......

i think, in general, if a program has 1-2 total imgs then people will always wonder if maybe those img's were just real superstars. But when a program is 80% img and DO, well some people have a certain opinion on that......not for the skill of the attendings really, but just of the quality of residents they are able to get.

I assumed the DO bias would be gone by the time one reached residency, bit I'm just a med student so what do I know.

 

[digitlnoize]

I assumed the DO bias would be gone by the time one reached residency, bit I'm just a med student so what do I know.

Don't worry, it is. I'm a DO and got an interview offer at 28/30 places I applied. It only lingers, like racism and homophobia, in the hearts and minds of a small minority. Probably the same minority, lol.

 

[notdeadyet]

I assumed the DO bias would be gone by the time one reached residency, bit I'm just a med student so what do I know.

Personally, I'd get away from the term "DO bias" and just call it what it is: snobbery.

Folks who look down on DOs also tend to look down their nose at IMGs. They also tend to look down their nose at less competitive allopathic schools. In which order just depends on how they view the pecking order in the hierarchy in their head.

I've noticed that these folks also tend to be big into the money side of things and debate endlessly about which specialties make more than others. The brash ones also often make it clear their opinion on Medicare patients. Again, it's just plain ole snobbery.

So do people looking down on DOs end with medical school? No, but you'll note it continues to become more rare as folks gain actual experience (including the life kind). And you will always have snobs who don't outgrow it. Such is life.

 

[vistaril]

if you're working a full work week, with one mid-level extender, seeing at least 3-4 patients per hour, there is plenty of potential for a very e income and provide good care, without having to stoop to being a pill mill.

midlevel extender in what capacity?

If you mean an lcsw/lpc doing therapy, these arent going to bring much real income to your practice. You are mainly taking those on to be able to accept referrals for med mgt because you're going to also need a therapy option of course for a lot of referrals. There just isn't enough "left over" from a midlevel therapy visit to make any real money after paying them, paying their benefits, etc....after all, if there was a huge chunk of money left over after their salary and benefits, the lcsw/lpc would just open their own practice(some do).....

If you mean a np/pa doing med mgt, well....I would say this is unethical. I have no idea why the person's primary physician would refer someone(in psych) to see a pa/np. If I were an internist that would never fly. I realize that it happens sometimes in procedure based fields, but that's a different setup because the primary care physician doesn't have the equipment to do some of those things in house, so they may refer to derm for example where a pa does it because the practice has that. Very different than psych.

 

[vistaril]

And some people have shown a remarkable ability to generalize from their own opinions and biases to judge programs and people about which they have no actual knowledge.

not sure how it is such when there is lots of data and real numbers on these things......psych community programs(as well as uni ones that function similar to community programs) have lots of IMGS...and then some do's sprinkled in as well.

people can read into that whatever they want.

 

[OldPsychDoc]

I agree that inpatient psychs can have an excellent lifestyle. But that's no different from IM/FP docs who work solely at the hospital too I guess. But the hospitalists work 7 on/7off so I was wondering why psych hospitalists don't work the 7 on/7 off but I guess due to the nature of the work, it's a little different and would be kind of unnecessary.

Just to come back to the OP (and move away from the urinary performance competition that has ensued)---you WILL see over the next few years more hospitals moving to 7-day coverage of some sort on psych units as well, simply for the fact that many payers, including the federal government, will start insisting that if a patient isn't sick enough to need a physician's attention, then perhaps they don't need acute hospitalization.

 

[OldPsychDoc]

Personally, I'd get away from the term "DO bias" and just call it what it is: snobbery.

Folks who look down on DOs also tend to look down their nose at IMGs. They also tend to look down their nose at less competitive allopathic schools. In which order just depends on how they view the pecking order in the hierarchy in their head.

I've noticed that these folks also tend to be big into the money side of things and debate endlessly about which specialties make more than others. The brash ones also often make it clear their opinion on Medicare patients. Again, it's just plain ole snobbery.

So do people looking down on DOs end with medical school? No, but you'll note it continues to become more rare as folks gain actual experience (including the life kind). And you will always have snobs who don't outgrow it. Such is life.

Some of whom will continue it on this very board from time to time....

 

[digitlnoize]

midlevel extender in what capacity?

If you mean an lcsw/lpc doing therapy, these arent going to bring much real income to your practice...after all, if there was a huge chunk of money left over after their salary and benefits, the lcsw/lpc would just open their own practice(some do)...

Not everyone wants to have their own practice, and yes, having a therapist midlevel can be profitable, although it's not going to be the biggest money maker, it can make money.

[/quote]If you mean a np/pa doing med mgt, well....I would say this is unethical. [/QUOTE]

Psych PA's are not uncommon in outpatient practice. Typically, they manage the patients who have been with the practice for a long time, and who have been stable for a long time, and whose typical visit only requires med refills.

These patients usually see the doctor occasionally too, and if the PA sees any deterioration of status, an appointment is set up with the doctor, or the doctor sees them right then, if that's possible/necessary. If done responsibly, midlevel extenders can be quite useful and very profitable.

I would agree that I'd be uncomfortable with a PA doing my intake evaluations or managing very unstable patients. At least, not until I was confident they were trained properly (i.e. my PA has been with me for 20 years and is a quite capable provider who I have trained well), and even then, I'd find it dicey...I have to do SOME work after all,

But back to the original discussion: If a job was 8-10 hour shifts 7 on, 7 off, and paid a reasonable salary, I could probably be talked into it. Still, seven 10h shifts is 70 hours a week, which I hate. I'd still rather have my own place and average 35 each week with the freedom to take off when I want...

 

[vistaril]

Psych PA's are not uncommon in outpatient practice. Typically, they manage the patients who have been with the practice for a long time, and who have been stable for a long time, and whose typical visit only requires med refills.
...

then these patients need to be referred back to their pcp and kept on this regimen if they are stable and "only requires med refills".

Anything else is a waste of resources and thus unethical.

I realizes it happens occasionally(although it's not super common in private practice...more common in cmhc's), but it's not right.

I'm not a pcp, but under no circumstances would I refer a pt to a psychiatrist and tolerate them only seeing the the pa for just refills. That is absurd.

 

[digitlnoize]

then these patients need to be referred back to their pcp and kept on this regimen if they are stable and "only requires med refills".

Anything else is a waste of resources and thus unethical.

I realizes it happens occasionally(although it's not super common in private practice...more common in cmhc's), but it's not right.

I'm not a pcp, but under no circumstances would I refer a pt to a psychiatrist and tolerate them only seeing the the pa for just refills. That is absurd.

Well, to each their own opinion. IMO, a well trained psych PA could pick up on more subtle psych pathology than a PCP, and thus is a better person to see for psych follow up.

 

[michaelrack]

I'm not a pcp, but under no circumstances would I refer a pt to a psychiatrist and tolerate them only seeing the the pa for just refills. That is absurd.

Most pcp's would be quite happy with this arrangement (referring to a psychiatrist who saw the patient initially, and then having the stabilzed pt see the psych's pa for refills). Most PCP's don't want to deal with things like monthly stimulant prescriptions of ADHD.

 

[vistaril]

Well, to each their own opinion. IMO, a well trained psych PA could pick up on more subtle psych pathology than a PCP, and thus is a better person to see for psych follow up.

if it's above the "comfort level" of a pcp, the pt would ideally be seen by a psychiatrist.

Even if you do disagree with that point, as apparently you do, you may have noticed that there is a...ummmm....problem with the allocation of health care resources in this country. The idea that bunches of health care resources should be regularly wasted on patients who are stable on a stable regimen and yet still need to go to and be billed by a psychiatrist but don't need to actually see the psychiatrist?......good luck selling that to hmos and whatever this system we are moving to in the future.

 

[vistaril]

Most pcp's would be quite happy with this arrangement (referring to a psychiatrist who saw the patient initially, and then having the stabilzed pt see the psych's pa for refills). Most PCP's don't want to deal with things like monthly stimulant prescriptions of ADHD.

"not wanting to deal" with a simple stable problem isn't a very good reason for continued referral imo.....