race to the bottom job offer....

[IamPsychiatrist]

have you paid attention at all in this thread, or are you just slow? I've never argued with those averages, or the idea that the salary I'm taking is low. I have stated that very very few psychiatrists anywhere practice under a model that I find reasonable. I'd rather practice in a way that provides at least an attempt at decent care than be assured of making above average salary.

You said your area couldn't charge much.

Survey says they charge much.

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[AthensBeth]

Maybe you addressed this earlier in the thread, but why the aversion to VA? You could work similar hours (sans the Friday half-day) and work as an outpatient VA psychiatrist and see patients in 45 minute blocks. The one I met during my med school rotations made 175 and seemed very happy.

 

[DJspreadsheet]

have you paid attention at all in this thread, or are you just slow? I've never argued with those averages, or the idea that the salary I'm taking is low. I have stated that very very few psychiatrists anywhere practice under a model that I find reasonable. I'd rather practice in a way that provides at least an attempt at decent care than be assured of making above average salary.

You have a talent for making attempts at disparaging psychiatry from every angle you can muster. It's clear your new angle is one needs to make a vow of poverty in order to even have a chance of providing legitimate care. Even with that you temper your language: "I'd rather practice in a way that provides at least an attempt at decent care"...a phrase loaded with ultimately fatalistic loopholes that you can glom onto in the future whenever you want to disparage further. And call me crazy, but you never struck me as the Mother Theresa type. I'm taking an educated guess and will say what you're doing is looking for the laziest job you can find, couching it under the veil of better service, and then letting your wife (who probably reads this forum, and is providing the impetus for you to create this fabricated moral stance) stick cameras in people's butts to pay your way.

 

[vistaril]

You said your area couldn't charge much.

Survey says they charge much.

again, I repeat- are you slow, or do you just refuse to actually read my comments/stance in this thread?

All the survey shows is that psychiatrists typically see a lot more patients than I will. I don't want to see that many patients per hour in an outpt setting. Thus I'll get paid less, which I accept.

 

[vistaril]

You have a talent for making attempts at disparaging psychiatry from every angle you can muster. It's clear your new angle is one needs to make a vow of poverty in order to even have a chance of providing legitimate care. .

I've always been very clear- psychiatry, imo, is a field in which one has to spend some time with patients to best understand their pathology. Taking appropriate time with outpts means you can schedule fewer, which means your revenue is less.

If other people think they can provide decent care under an insurance based model seeing patients for short amounts of time, good for them. That's their choice.

 

[vistaril]

Maybe you addressed this earlier in the thread, but why the aversion to VA? You could work similar hours (sans the Friday half-day) and work as an outpatient VA psychiatrist and see patients in 45 minute blocks. The one I met during my med school rotations made 175 and seemed very happy.

well you can't see patients at most VAs in 45 minute blocks....then again there are so many cancellations and no shows that you could probably average much more time per pt than that.

The problem with the VA is that most of the outpatient population is one of the following:

1) not that sick
2) not invested in getting better
3) FOS

And I greatly respect the people who have served our country. But the va is not about that. The VA is just one massive, and I mean MASSIVE, federal jobs and benefits program. I'd prefer to actually practice mental health and not enroll in such a thing.

 

[st2205]

I've always been very clear- psychiatry, imo, is a field in which one has to spend some time with patients to best understand their pathology. Taking appropriate time with outpts means you can schedule fewer, which means your revenue is less.

If other people think they can provide decent care under an insurance based model seeing patients for short amounts of time, good for them. That's their choice.

This is true about every specialty, though. I don't know why the assumption has been made that this is somehow a more reasonable and ethical philosophy in a PCP setting. In that comparison very few fields of medicine really differ from each other in that you're sacrificing quality of care for quantity. It's been oft brought up that the potential income in other fields is so much more, but that potential isn't achieved by going high volume and somehow managing to still be providing great care by some kind of spontaneous magic. The argument can be made that it is, but we'd be fooling ourselves.

Anyhow, I think you mentioning that you haven't disputed average salaries in this thread is a wise move, because you haven't. I would assume you'd have enough sense to know people are referring not to this thread alone but to the years that you've been arguing that those salaries aren't real averages. Now that that argument seems to have been largely discredited the goalpost seems to have been shifted to state that these averages reflect less ethical/quality-of-care practice.

 

[vistaril]

This is true about every specialty, though. I don't know why the assumption has been made that this is somehow a more reasonable and ethical philosophy in a PCP setting. In that comparison very few fields of medicine really differ from each other in that you're sacrificing quality of care for quantity. It's been oft brought up that the potential income in other fields is so much more, but that potential isn't achieved by going high volume and somehow managing to still be providing great care by some kind of spontaneous magic. The argument can be made that it is, but we'd be fooling ourselves.

Anyhow, I think you mentioning that you haven't disputed average salaries in this thread is a wise move, because you haven't. I would assume you'd have enough sense to know people are referring not to this thread alone but to the years that you've been arguing that those salaries aren't real averages. Now that that argument seems to have been largely discredited the goalpost seems to have been shifted to state that these averages reflect less ethical/quality-of-care practice.

no, it's not true about every specialty. Not at all. It is common sense that, in modern medicine, psychiatry takes more time per patient because we have fewer(or no in many cases) labs, workup, tests. Many medicine subspecialists can effectively and efficiently bill for followup appts simply by checking the results of a lab or test and then taking the next step. We can't do that. That's why medicine docs can move so much more volume than us.

And I never said that many salaries aren't real averages. It's actually been others in here who have said that many of the listed salaries aren't real averages. 185k or whatever sounds like a perfectly reasonable median for the average full time psych. My problem is I have no interest in doing what the average psych does in terms of a practice model.

 

[Nasrudin]

no, it's not true about every specialty. Not at all. It is common sense that, in modern medicine, psychiatry takes more time per patient because we have fewer(or no in many cases) labs, workup, tests. Many medicine subspecialists can effectively and efficiently bill for followup appts simply by checking the results of a lab or test and then taking the next step. We can't do that. That's why medicine docs can move so much more volume than us.

And I never said that many salaries aren't real averages. It's actually been others in here who have said that many of the listed salaries aren't real averages. 185k or whatever sounds like a perfectly reasonable median for the average full time psych. My problem is I have no interest in doing what the average psych does in terms of a practice model.

You're lack of appreciation for the time squeeze in other specialties is astounding. I don't know all the nooks and crannies of internal medicine sub-specialties but in primary care and peds it's ridiculous what you have to squeeze into short visits--this I'm certain of. Although following your conversational loops sometimes makes me vaguely foggy on everything. You're somewhat of an evil genius in this regard. We need a comic book villain name for you.

Weren't you questioning the value of service that could be achieved by people in private practice with more time to spend with patients? Did I remember grumbling in my head over Vistaril #9's rejection of value added for this. And then this Vistaril is saying he needs at least X amount of time per patient per this or that to practice at the lofty level he is comfortable with. "Of course, nothing against you 99% old boy..."

You're a shape shifter. A time-space warping factor.

 

[notdeadyet]

The problem with the VA is that most of the outpatient population is one of the following:

1) not that sick
2) not invested in getting better
3) FOS

Well, since you're talking about the veteran demographic and not a racial group, you can't really be called racist... Though these kind of generalizations (so often followed by "but I really respect those who've served..." or "But I have a lot of African American friends...") sure sound familiar.

But as someone who spends a lot of time serving veterans both while in uniform and our of uniform, I am quite okay with your not wanting to work the VA. Carry on....


Sent from my iPhone using Tapatalk

 

[notdeadyet]

Anyway, this is turning back into one of those familiar threads.

Vistaril- I wish you luck, dude, and I hope your gig works out. If it doesn't there are LOTS of other gigs out there. But I don't know what your resume looks like, what bridges you may have built vs burned, or how you come across in interviews, so I don't know how limited your options have turned out to be.

I'm just hoping this doesn't turn into one of those things where you start generalizing about prospects in the field because of what's available to you as an individual. As you've heard from lots of other folks from all over, what you're looking at ain't the norm. It's easy to talk about how low the ceiling is when you're crouched under a table.

Best of luck with the gig. I hope it's what you've hoped.


Sent from my iPhone using Tapatalk

 

[vistaril]

Anyway, this is turning back into one of those familiar threads.

Vistaril- I wish you luck, dude, and I hope your gig works out. If it doesn't there are LOTS of other gigs out there. But I don't know what your resume looks like, what bridges you may have built vs burned, or how you come across in interviews, so I don't know how limited your options have turned out to be.

I'm just hoping this doesn't turn into one of those things where you start generalizing about prospects in the field because of what's available to you as an individual. As you've heard from lots of other folks from all over, what you're looking at ain't the norm. It's easy to talk about how low the ceiling is when you're crouched under a table.

Best of luck with the gig. I hope it's what you've hoped.


Sent from my iPhone using Tapatalk

you're still not fully grasping what I'm saying here or how I feel about mental health opportunities. There isn't any doubt that 'what I'm looking at' is very very similar to what everyone else in this forum(mostly) is looking at. We just look at it differently. The one exception is probably that I believe pp cash pay psychs successfully charging 300-400 dollars/hr are not as feasible as you guys do.

And you don't need to speculate on my options- my options are probably about the same as many others. I didn't burn any bridges or anything like that. I'm doing what I'm doing because I:

1) do not believe ethical or effective mental health outpt is accomplished by high volume med mgt
2) don't believe patients really get better on inpatient units
3) don't believe I have a skill set to do longer outpt appts that are cash pay at the rates you guys talk about

I've done plenty of 1 and 2 moonlighting, and everytime I got home felt like I had to take a shower. Life is too short to feel that way. Most people out of residency who don't take a job in academics do 1 or 2. Apparently they don't have the same issues with it.

It's really that simple.

 

[vistaril]

Well, since you're talking about the veteran demographic and not a racial group, you can't really be called racist... Though these kind of generalizations (so often followed by "but I really respect those who've served..." or "But I have a lot of African American friends...") sure sound familiar.

But as someone who spends a lot of time serving veterans both while in uniform and our of uniform, I am quite okay with your not wanting to work the VA. Carry on....


Sent from my iPhone using Tapatalk

I have spent a ton of time working at VAs as well. But I don't see how anyone could believe that in it's current form it is a good system. Just look at the current VA disability apps(and backlog) for starters.....it's a giant cluster.

 

[vistaril]

You're lack of appreciation for the time squeeze in other specialties is astounding. I don't know all the nooks and crannies of internal medicine sub-specialties but in primary care and peds it's ridiculous what you have to squeeze into short visits--this I'm certain of.

So many primary care appts are problem focused to the point that they can be very quick. What % of outpt pp peds appts are for ear infections or uris for example? primary care docs can fly through those without really sacrificing pt care in any meaningful way.

 

[Nasrudin]

Hahahaha!

You felt like you had to take a shower = unbearable drudgery. The horror!

You're clueless. They have to manage everything we manage just the psych issues and by you're own depiction wouldn't dream of venturing out of our narrow sector. You have no f'n clue what it takes for a pediatrician to be a good pediatrician in the financial pressure cooker that has them eeking out low ball salaries by comparison to ours. Vistaril the pediatrician wouldn't be able to find a job that he could ethically stomach, queasy as he is, bless his heart.

I'm tapping out bro. Unlike some of my more genteel brethren I don't wish you luck. I wish you the balls to make your luck.

 

[Ceke2002]

I have to admit reading a Vistaril thread is like watching the unfolding of some mercurially brilliant performance art piece.

 

[michaelrack]

So many primary care appts are problem focused to the point that they can be very quick. What % of outpt pp peds appts are for ear infections or uris for example? primary care docs can fly through those without really sacrificing pt care in any meaningful way.

You overestimate the ease of flying through primary care appts. While I don't know much about peds, I can tell you that it isn't easy to fly through general internal medicine appts- and those docs that do are the ones who tend to overprescribe abx, and provide lower quality care in general. Sure, quick visits can be done in IM, just like in psychiatry a psychiatrist can work in a comm mental health center and see psychotic pts every 3 months, ask them if they are hallucinating or suicidal, and if not refill antipsychotic in less than 5 minutes- either way, it's not good care. Good primary care and good psychiatry both require time.

 

[Psychotic]

V is trolling. Why are you guys feeding him?

 

[AthensBeth]

well you can't see patients at most VAs in 45 minute blocks....then again there are so many cancellations and no shows that you could probably average much more time per pt than that.

The problem with the VA is that most of the outpatient population is one of the following:

1) not that sick
2) not invested in getting better
3) FOS

And I greatly respect the people who have served our country. But the va is not about that. The VA is just one massive, and I mean MASSIVE, federal jobs and benefits program. I'd prefer to actually practice mental health and not enroll in such a thing.

Wait, so...the private sector is a good system? And it ensures just the kind of sick patients that are invested in getting better that you prefer to see? You don't have control over that in the private sector either, and from what I've seen, it is riddled with problems too. "Non-profit" hospitals with people sitting on the board making huge salaries, "chargemasters," doctors being reprimanded for not admitting enough patients, etc... I hate when people put down "big governement" or the fed, acting like the private sector does everything better. Yeah, there has been some problems with the VA that have been exposed lately, but there have been much more sketchy things happening in private hospitals, in my opinion.

 

[F0nzie]

I am sure pediatricians experience the time crunch and many other specialties have their own set of issues. Psychiatry, however, is unique in that we have a disproportionately high % of the anxious, the circumstantial and tangential, the hyperverbal, the abandoned, the narcissistic, the helpless & hopeless, the speech impoverished, the family cluster, etc. It's much harder for me to derail a patient and focus on my checklist when I know that helping them process experiences and allow room for expression is a very important key to their recovery. For example, let's say I have a patient that was abused and neglected-- I cut them off, write a prescription, and unknowingly create an invalidating experience for the patient who has now attached a negative meaning to the medication...it's not up to the social worker to address that in therapy. It's my problem because it's my patient.

 

[TexasPhysician]

Everyone please remember to stay civil. There is no requirement to be 100% appreciative of the current state of psychiatry. Everyone has different preferences and desires.

Everyone is entitled to their opinion, but as you post, remember to be respectful.

 

[Armadillos]

I think it is worth everyone remembering Vistaril is a a professional troll who gets some sort of very strange pleasure from stirring up trouble.

1) He goes to the pharmacy board to troll the pharmacists

but even that rather well done onion article isn't a perfect analogy here because at coffee/pastry shops there *is* some degree of difference and room to stand out/separate from competition in terms of the actual product(and not just the service around it). For example, Atlanta bread company bagels are bland imo, but panera seems to have a little more kick.

But in pharmacy, there is no way to do that on the product itself. 5mg lisinopril is 5mg lisinopril.

yep....I do think retail pharms would catch more useful errors if they had useful data. Of course the downside to that(having more information and actually trying to serve some sort of clinical role/safeguard) would be that production would slow dramatically and profits would decrease(and theerefore salaries)....

is involvement in patient care at that level(GED medical assistant level) the kind of involvement you want though?

2) He goes to the optometry board to troll the optometrists (but is still sure to get a dig in on psych!)

It just seems like the worst economic model I have ever seen.....and I liked the guy after my encounter with him, but I can't believe he is happy or has any satisfaction doing that. What % of opto's do this kind of work? If I went to school for 4 years *after college* to do that in that environment and make whatever it is he makes(70K???) I would be miserable. I say this as someone who practices in the most looked down upon and least respected specialties in all of medicine(psychiatry), so I'm definately not trying to antagonize or anything....I just felt bad for the guy and hope he is just going through a rough spot in his career.

The fields, except that they are professional schools related to health in some way, have little in common.

Dentistry is a procedure/surgical based field. Optometry is not. Dentistry is also a field where residency training(at least in the form of a general practice residency) is pretty much the minimum standard for new grads. That is not the case in optometry. And while the individual percentages of endodontists, orthodontists, periodontists, pediatric dentists, OMF's, etc is pretty small, adding up *ALL* these dental subspecialties together with people graduating now shows that a large number of new grads are pursuing these areas, often after a GPR year or two.

I would also bet that dental school is far more taxing in terms of work hours and intensity than optometry school. Having gone to a medical school that also had a dental school, I knew plenty of dental students and saw hour busy they were years 1 through 4. They work *hard*....harder than medical students in most cases, and often by a good bit. The number of cases/procedures they have to master in dental school(while completing all the 'book' study work) is massive. It is not uncommon for dental schools to average 65 or so hours of work per week(actual work, not sitting around waiting for patients to come) throghout dental school. By contrast, if this forum is any indication OD school is much less rigoruous in terms of the intensity of training. And I don't say that as a criticism- I suspect a lot of OD students wouldnt want to work like dental students.

Another obvious difference is that dentists are the apex providers in their field, whereas in eye care optometrists obviously aren't.

Most importantly, competition to enter these two fields is in no way similar. Optometry school, and more importantly the difficulty in getting into some optometry school, is not all that difficult. Optom school applicants to total spots is now less than 1.4/1, and that's before considering how there is a lot of self selection *in* to optometry school from more competitive schools in the first place. I wouldn't pretend to know what exact percentage of optom school matriculants could have gotten into dental school somewhere, but it's almost certainly pretty low. Furthermore, it's more than just about stats....where I went to med school the dental students tended to either have undergrads from either the well respected large state university(ie not regional smaller universities that are less competitive) or impressive private undergrads that are top 25 nationally(Duke, Vanderbilt, etc)....there were very few people from smaller less regarded regional state schools with lesser standards. Something to keep in mind when comparing one 3.6 to another 3.6.

So I'm just puzzled to see so much advice along the lines of 'you should consider dental school instead of optometry school'. Ummm...ok...by that same reasoning I should have considered going to PGA tour qualifying school. PGA tour golfers make a lot more than I am making now, have more autonomy, better hours, etc....

3) He goes to the pathology board to troll the pathologists

http://forums.studentdoctor.net/thr...-for-gi-practices-to-pay-pathologists.978699/

 

[Nasrudin]

I am sure pediatricians experience the time crunch and many other specialties have their own set of issues. Psychiatry, however, is unique in that we have a disproportionately high % of the anxious, the circumstantial and tangential, the hyperverbal, the abandoned, the narcissistic, the helpless & hopeless, the speech impoverished, the family cluster, etc. It's much harder for me to derail a patient and focus on my checklist when I know that helping them process experiences and allow room for expression is a very important key to their recovery. For example, let's say I have a patient that was abused and neglected-- I cut them off, write a prescription, and unknowingly create an invalidating experience for the patient who has now attached a negative meaning to the medication...it's not up to the social worker to address that in therapy. It's my problem because it's my patient.

Ok. But PCP's of any sort could give a similar litany of offenses against the logic of time-pressured appointments. Old lady can't remember her 15 meds but has a bunch of bottles in her purse, a host of vague complaints, tons of medical problems, and perhaps psych issues, and sure maybe you're the only person in her life giving her passing regard, so time spent with her is therapeutic as well. It's the same story in most of medicine. We can't all be dermatologists and so here we are.

So I would like to see how you address the thrust of vistaril's thesis as you seem to have the patience--what does the proper work balance entail? Do we have the skill set to validate 150 K without running high volume crappy practice? If we all see 7 patients a day at 45 min to an hour a pop, how do all the patients that need a psychiatrist get seen? Does that matter or is luxury and personal satisfaction what we're calling equitable or ethical?

Can we all do what you or Vistaril are doing? Is that how we become ethical, sensitive providers, not beholden to corrosive monetary incentive? Can we all marry professionals of top earning potential to make these financial suicide moves as ignoble as they are vistaril's case? Surely if we all had trust funds we could practice psychoanalysis for hours at a time in rural subsaharan Africa for pennies. And wouldn't the world be better for it.

Etc.

 

[Nasrudin]

Wow, thanks armadillos and psychotic. My problem is trolling is not something I understand motivationally. Boggles my mind they could be this elaborate. Thanks again.

 

[AthensBeth]

I think it is worth everyone remembering Vistaril is a a professional troll who gets some sort of very strange pleasure from stirring up trouble.


When you say he's a professional troll, do you mean that he's a professional and a troll or that it's his profession that he gets paid for? If it's the latter, maybe this could help supplement his income and pay his IBR payments.

 

[Therapist4Chnge]

Many psychiatrists will be magnitudes better than lcsw's.

To be fair to LCSWs....citation please?

 

[IamPsychiatrist]

To be fair to LCSWs....citation please?

It's an opinion. Also, taken in context - the question was can a psychiatrist deliver better therapy than an LCSW? My belief is that our training in biology, medicine and pathophysiology can help with therapy. I don't need research to solidify that belief. And the only people I hope to persuade of this are my patients (not lcsws or academia) - and my fellow laborers of same mind. We only have so much time in this life.

I don't believe citations are prerequisites to thought. Nor does publication = truth.

Ok. But PCP's of any sort could give a similar litany of offenses against the logic of time-pressured appointments. Old lady can't remember her 15 meds but has a bunch of bottles in her purse, a host of vague complaints, tons of medical problems, and perhaps psych issues, and sure maybe you're the only person in her life giving her passing regard, so time spent with her is therapeutic as well. It's the same story in most of medicine. We can't all be dermatologists and so here we are.

So I would like to see how you address the thrust of vistaril's thesis as you seem to have the patience--what does the proper work balance entail? Do we have the skill set to validate 150 K without running high volume crappy practice? If we all see 7 patients a day at 45 min to an hour a pop, how do all the patients that need a psychiatrist get seen? Does that matter or is luxury and personal satisfaction what we're calling equitable or ethical?

Can we all do what you or Vistaril are doing? Is that how we become ethical, sensitive providers, not beholden to corrosive monetary incentive? Can we all marry professionals of top earning potential to make these financial suicide moves as ignoble as they are vistaril's case? Surely if we all had trust funds we could practice psychoanalysis for hours at a time in rural subsaharan Africa for pennies. And wouldn't the world be better for it.

Etc.

Vistaril seems clueless.

I've seen many PCP providers diagnose and treat depression, anxiety, bipolar, and many other disorders in 2 minutes. All in a 10-15 minute appointment that also is dealing with 3-4 other chronic problems.

If someone getting 2 minutes with a PCP gets 20 minutes with a better trained practitioner for their specific aliments - that's a win in my book.

There's a balance between being thorough and efficient. It's a false assumption to think that 45-60 minutes = better care. There are psychiatrists out there that do much better in 20 minutes than hacks do in 60 minutes (no citation - opinion!)

 

[Ceke2002]

what does the proper work balance entail? Do we have the skill set to validate 150 K without running high volume crappy practice? If we all see 7 patients a day at 45 min to an hour a pop, how do all the patients that need a psychiatrist get seen? Does that matter or is luxury and personal satisfaction what we're calling equitable or ethical?

I have no idea how he actually manages it, but my Psychiatrist runs a private Psychotherapy clinic, works as the lead clinician in a large area Government clinic, is a senior clinical lecturer, a residency supervisor, and has sat on the board of curriculum at one of the main schools of medicine where I live. In the conversations I've had with him it would appear he has an excellent work life balance, and derives a lot of satisfaction from his job. I can't speak for other patients, but he certainly doesn't just rush me in and out with a quick 5-10 minute med management check as Vistaril would seem to think was the lot of Psychiatrists in his area. It seems, to me at least, in Vistaril's mind you're either a Government clone pushing slabs of meat around (I'm picturing Vistaril slinging large human shaped sacs around with the word 'Patient' stamped across them), or you only see a limited number of patients, and you can't charge them over a certain amount, and oh the humanity. I think it is possible to actually combine different aspects into one cohesive whole, whilst still achieving job satisfaction, making enough money to live comfortably and having time to pursue your own interests/take care of your family.

 

[vistaril]

I am sure pediatricians experience the time crunch and many other specialties have their own set of issues. Psychiatry, however, is unique in that we have a disproportionately high % of the anxious, the circumstantial and tangential, the hyperverbal, the abandoned, the narcissistic, the helpless & hopeless, the speech impoverished, the family cluster, etc. It's much harder for me to derail a patient and focus on my checklist when I know that helping them process experiences and allow room for expression is a very important key to their recovery. For example, let's say I have a patient that was abused and neglected-- I cut them off, write a prescription, and unknowingly create an invalidating experience for the patient who has now attached a negative meaning to the medication...it's not up to the social worker to address that in therapy. It's my problem because it's my patient.

yes to all of this.

 

[vistaril]

You overestimate the ease of flying through primary care appts. While I don't know much about peds, I can tell you that it isn't easy to fly through general internal medicine appts- and those docs that do are the ones who tend to overprescribe abx, and provide lower quality care in general. Sure, quick visits can be done in IM, just like in psychiatry a psychiatrist can work in a comm mental health center and see psychotic pts every 3 months, ask them if they are hallucinating or suicidal, and if not refill antipsychotic in less than 5 minutes- either way, it's not good care. Good primary care and good psychiatry both require time.

I think a big push now in the outpt pc world is to schedule appts to limit the number of problems that can be focused on 1 appt. If I were a pcp doing outpt there is no way I would accept pts on 15 meds with 7 chronic illnesses who want to handle each one of those at every appt.

I guess I am also thinking of the times I have encountered pcps as a pt in the outpt world. They were in the room maybe 1-2 minutes(maybe less), and I certainly don't think my care suffered. Whereas if I had been a psych pt and that happened, I would have thought it was care limiting.

 

[IamPsychiatrist]

The idea that general IM has an easy path running high volume without sacrificing for care and psychiatry has difficulty doing this is false.

More time doesn't = higher quality

____________________________

Vistaril will continue to hold his limiting beliefs and negative attitudes. Convincing him of anything isn't worthwhile. Others will assume that they have a unique difficulty in setting up their practice that other doctors don't face (the grass is greener!).

The rest of us can focus on being excellent at what we do and helping patients efficiently.

Those who think they are interchangeable with midlevels, equivalent in therapy skills to those with 10% of their training, and have a general pessimistic attitude will flounder while those who believe their training was valuable, have an attitude of excellence alongside exceptional services, and a positive attitude will flourish. Give the later 20 minutes and he will do more than the former in 2 hours.

 

[billypilgrim37]

I absolutely admit that I could not bear to read this entire thread so I may be off, but about 100 posts in it looked like Vistaril was saying he found a job he felt okay about in an area that is somewhat limited geographically. Just speculation, but maybe his GI gal got a great offer around there and so he's a bit limited geographically? He prioritized not having to see patients too quickly (as he said, ethical), and he's working under 40 hours a week. Yes the lack of benefits is disappointing and this isn't a super sweet deal, but I got the sense that he was really happy with it and was prioritizing patient care and lifestyle over income.

What am I missing? (granted, I skipped large blocks because it seemed like it was getting crazy)

Congrats, V. It sounds like you feel good with this, and that's awesome.

 

[Ceke2002]

What am I missing? (granted, I skipped large blocks because it seemed like it was getting crazy)

What to some of us may have sounded like much wailing and gnashing of teeth, for Vistaril was probably an oration of great tidings. I do believe he might just have the uncanny ability to suck the life marrow out of any titbit of good news.

Just hazarding a guess.

 

[F0nzie]

So I would like to see how you address the thrust of vistaril's thesis as you seem to have the patience--what does the proper work balance entail? Do we have the skill set to validate 150 K without running high volume crappy practice? If we all see 7 patients a day at 45 min to an hour a pop, how do all the patients that need a psychiatrist get seen? Does that matter or is luxury and personal satisfaction what we're calling equitable or ethical?

I do not see spending 45 min with a psychiatrist in therapy as a luxury. I see it as a necessity in many cases. Eventually you will hit remission and 15-20 min works out great for touching base and monitoring until relapse. 7 patients per day at 45 min each is just not realistic even in the idealest of situations. In my pp I am already switching my therapy patients to brief med checks because they are getting better. It's critical to foster the progression toward greater independence and spark their sense of agency.

In situations where the follow ups are set to 20 min by default I try to make the best out of a bad situation. If I have a cancellation or a no show I'll try and fit in a bit of therapy.

My advice-- Don't be complacent. At my part-time job the older psychiatrists that trained in the psychotherapy era recently fought for 1.5 hour evals and were able to get it passed through the administration. Per my request I was also granted 1 hour therapy sessions for one of our high acuity Borderline PD patients. My case manager with over a decade of experience in the field was like "Really? That's great. I've never heard of a Psychiatrist doing that".

 

[vistaril]

I absolutely admit that I could not bear to read this entire thread so I may be off, but about 100 posts in it looked like Vistaril was saying he found a job he felt okay about in an area that is somewhat limited geographically. Just speculation, but maybe his GI gal got a great offer around there and so he's a bit limited geographically? He prioritized not having to see patients too quickly (as he said, ethical), and he's working under 40 hours a week. Yes the lack of benefits is disappointing and this isn't a super sweet deal, but I got the sense that he was really happy with it and was prioritizing patient care and lifestyle over income.

What am I missing? (granted, I skipped large blocks because it seemed like it was getting crazy)

Congrats, V. It sounds like you feel good with this, and that's awesome.

yep that pretty much sums it up. thanks.

 

[vistaril]

The idea that general IM has an easy path running high volume without sacrificing for care and psychiatry has difficulty doing this is false.

More time doesn't = higher quality

____________________________

Vistaril will continue to hold his limiting beliefs and negative attitudes. Convincing him of anything isn't worthwhile. Others will assume that they have a unique difficulty in setting up their practice that other doctors don't face (the grass is greener!).

The rest of us can focus on being excellent at what we do and helping patients efficiently.

Those who think they are interchangeable with midlevels, equivalent in therapy skills to those with 10% of their training, and have a general pessimistic attitude will flounder while those who believe their training was valuable, have an attitude of excellence alongside exceptional services, and a positive attitude will flourish. Give the later 20 minutes and he will do more than the former in 2 hours.

how in the world do midlevels(assuming you mean lpcs and lcsws) have 10% of our training when it comes to therapy? I'm interested in doing some degree of therapy obviously, and ask experienced midlevel therapists all the time for help with cases. When it comes to therapy, many experienced midlevel clinical therapists are better than most young psychiatrists. Certainly better than me at this point.

Now that doesn't mean every lcsw/lpc is a skilled therapist I learn from. But it's generally known who the skilled ones are.

 

[Nasrudin]

I do not see spending 45 min with a psychiatrist in therapy as a luxury. I see it as a necessity in many cases. Eventually you will hit remission and 15-20 min works out great for touching base and monitoring until relapse. 7 patients per day at 45 min each is just not realistic even in the idealest of situations. In my pp I am already switching my therapy patients to brief med checks because they are getting better. It's critical to foster the progression toward greater independence and spark their sense of agency.

In situations where the follow ups are set to 20 min by default I try to make the best out of a bad situation. If I have a cancellation or a no show I'll try and fit in a bit of therapy.

My advice-- Don't be complacent. At my part-time job the older psychiatrists that trained in the psychotherapy era recently fought for 1.5 hour evals and were able to get it passed through the administration. Per my request I was also granted 1 hour therapy sessions for one of our high acuity Borderline PD patients. My case manager with over a decade of experience in the field was like "Really? That's great. I've never heard of a Psychiatrist doing that".

Ok this is a useful perspective--one that I'll try to process as I advance. But it sidesteps both V's thread topic and how I put it to you as well. To what extent are we under control of these things. These old psychiatrists spending an hour or more with patients--to what extent is that just some near retirement doc with money stuffed away and no pressure to move the meat. The premise is that there is race towards the bottom. Well, I'm sorry, but you're a private practice guy, one that presumably left the normative scenario for a reason, from another 2 physician income unit servicing wealthier cash paying patients, and your other examples are from people who remember when Nixon was in office. Those are different economic scenarios.

I want to know the validity of the normal being implied. I'll heed your example of pushing back against the tide, because that makes sense. But I'm interested in more public/community delivery models. And from what I can tell these systems are under the sort of financial stress and pressure that they would not support entire departments full of aging, chillaxing baby boomers who are phasing our their careers over decades.

Vistaril's approach is one for made men. Congrats on that. But I'm less convinced it represents batting a triple for patient advocacy so much as starting on third base and moseying home.

 

[eaglepsych]

The good news is, folks, that once you're out and practicing for a few years you typically figure out more of what you like/don't like, how much money vs. work/life balance it takes to be happy, etc. you also find out how good of a psychiatrist you are, which undoubtedly plays a role in what your choices are moving forward.

No matter where you start (job wise), if you are good at what you do you will be capable of a satisfying and rewarding career-no different in psychiatry than any other job. Take the job that "feels right" to you and dont care too much what others think, and do good to your patients and colleagues, and that aspect of our life tends to work out just fine.

Posting this for med students/residents reading this thread who are probably getting confused just reading this thread.

 

[IamPsychiatrist]

how in the world do midlevels(assuming you mean lpcs and lcsws) have 10% of our training when it comes to therapy? I'm interested in doing some degree of therapy obviously, and ask experienced midlevel therapists all the time for help with cases. When it comes to therapy, many experienced midlevel clinical therapists are better than most young psychiatrists. Certainly better than me at this point.

Now that doesn't mean every lcsw/lpc is a skilled therapist I learn from. But it's generally known who the skilled ones are.

You are correct. Lcsws offer better comprehensive care than you, and a Lcsw + NP with Rx rights would eliminate the need for your services.

Don't include the rest of us on your sinking ship.

I'm not going to argue about the time it takes to train a physician compared to a social worker. Your pursuit of the negative and limitations are unrivaled.

 

[vistaril]

I'm not going to argue about the time it takes to train a physician compared to a social worker. Your pursuit of the negative and limitations are unrivaled.

the issue here, yet again, is that you have decided to argue a point not made. The amount of time it takes to train a psychiatrist is largely irrelevant to my point. The correct comparison is the number of therapy hours clinically oriented lcsws/lpcs get as compared to many psychiatrists.

 

[IamPsychiatrist]

the issue here, yet again, is that you have decided to argue a point not made. The amount of time it takes to train a psychiatrist is largely irrelevant to my point. The correct comparison is the number of therapy hours clinically oriented lcsws/lpcs get as compared to many psychiatrists.

Exactly. I believe that the authority of an MD, the knowledge of pathophysiology and medicine can impact the therapy.

To quote Aristotle: "The whole is greater than the sum of its parts"

Let's end the discussion. It's not worthwhile to either of us, nor this forum. You are not a worthwhile person to have discussions with. I've let your negativity fill 15 minutes of my day - which is a waste! (I placed you on ignore because I'm trying to limit bad influences).

Edit: Wow, you guys should try the ignore feature - it not only eliminates his posts but it also eliminates all his quotes in everyone's posts. It's Prozac for SDN.

 

[Leo Aquarius]

Everybody! Quick! use your ignore feature!

 

[vistaril]

Exactly. I believe that the authority of an MD, the knowledge of pathophysiology and medicine can impact the therapy.

To quote Aristotle: "The whole is greater than the sum of its parts"

Let's end the discussion. It's not worthwhile to either of us, nor this forum. You are not a worthwhile person to have discussions with. I've let your negativity fill 15 minutes of my day - which is a waste! (I placed you on ignore because I'm trying to limit bad influences).

Edit: Wow, you guys should try the ignore feature - it not only eliminates his posts but it also eliminates all his quotes in everyone's posts. It's Prozac for SDN.

well you're free to end the discussion anytime you want, but as long as I have something to say on a matter I'll post.

Unfortunately, as with many of your posts in this thread, you make a lot of statements without attempting to support them. Or even discuss why you feel that way.

Let's take what we can probably agree is a very common therapy patient: a non-smi woman diagnosed with GAD and dysthymic d/o. Her main issues right now are battling with her siblings over how to care for their ailing elderly mother as well as setting firm limits with her 2 children who are running all over her. How can my knowledge of pathophysiology improve the therapy with her? I'm not being snarky- I just don't know and perhaps you can educate me.(if you can manage to stay on point and not argue against a strawan)

 

[edgerock24]

the issue here, yet again, is that you have decided to argue a point not made. The amount of time it takes to train a psychiatrist is largely irrelevant to my point. The correct comparison is the number of therapy hours clinically oriented lcsws/lpcs get as compared to many psychiatrists.

What you've just said is one of the most insanely idiotic things I have ever heard. At no point in your rambling, incoherent response were you even close to anything that could be considered a rational thought. Everyone in this room is now dumber for having listened to it. I award you no points, and may God have mercy on your soul.

 

[vistaril]

What you've just said is one of the most insanely idiotic things I have ever heard. At no point in your rambling, incoherent response were you even close to anything that could be considered a rational thought. Everyone in this room is now dumber for having listened to it. I award you no points, and may God have mercy on your soul.

maybe you don't agree with what I wrote above(then again you don't say anything of substance either way), but it was unquestionably coherent and to the point.

 

[PrideNeverDie]

maybe you don't agree with what I wrote above(then again you don't say anything of substance either way), but it was unquestionably coherent and to the point.

he is quoting Billy Madison

 

[TexasPhysician]

maybe you don't agree with what I wrote above(then again you don't say anything of substance either way), but it was unquestionably coherent and to the point.

I'm assigning you homework. Billy Madison is a top notch movie that everyone should instantly recognize.

 

[SteinUmStein]

 

[michaelrack]

What you've just said is one of the most insanely idiotic things I have ever heard. At no point in your rambling, incoherent response were you even close to anything that could be considered a rational thought. Everyone in this room is now dumber for having listened to it. I award you no points, and may God have mercy on your soul.

the issue here, yet again, is that you have decided to argue a point not made. The amount of time it takes to train a psychiatrist is largely irrelevant to my point. The correct comparison is the number of therapy hours clinically oriented lcsws/lpcs get as compared to many psychiatrists.

While it is unclear if vistaril recognized the Billy Madison point, I don't think his point is idiotic. Vistaril's point appears to be that the # of hours in training that one receives in therapy is more important in producing an effective psychotherapist than one's underlying profession or medical knowledge.
On the other hand, Iampsychiatrist states "the authority of an MD, the knowledge of pathophysiology and medicine can impact the therapy". There is probably some truth to both points of view.

 

[Addiction]

I posted the below information on a previous thread started by Vistaril recently. APA has been able to successfully lobby CMS into higher rates for psychotherapy provided by psychiatrists (MD's) when doing medication management starting this year. I believe an add-on psychotherapy code of 90833 (16-27 minutes) pays an additional ~1.8 RVUs or ~$60. Therefore, a 20-25 minute visit where you spend 5-10 minutes of med management with 16 minutes of time dedicated to therapy would now pay (99213+90833) $125-130 at Medicare rates. Before switching to E&M (prior to 12/31/2012) the same service would be billed as a 90805 and pay ~$70-75. This is a significant increase in reimbursement for the same service. Overall, this means you can schedule 2 follow-ups per hour and do OK.