So can we talk money?

[TexasPhysician]

The concern a lot of people in derm have is that the way they sometimes maintain those volumes is by biopsying 90% of what walks into their clinic and sending it off to a pathologist. It turns out that a nurse practitioner is just as qualified to do this as someone with an MD. Obviously you will not see NPs doing Mohs any time soon but punch/shave mills are just one CMC meeting away from getting ophtho'd

Won't happen. No one wants to get unnecessarily biopsied. You are paying for the knowledge to identify risks effectively. Every derm I know has a great clinic.

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[honsano]

I'm curious how people are pulling salaries >250K. It'd help us figure out ways to efficiently earn more money.

My VA job right now salaries me at 220K with no call or weekends. With my additional board cert, I'll be at 230K. With bonuses, which are easily accessible, that'll be 245K (I see people talk about the VA a lot but no one mentions the bonus structure which basically is just easy money). I work four 10's at the VA. On my day off, I work a prison gig (good money) or do forensic evals (poor money but intellectually satisfying) for the state. That puts me around 300k for about 50 hours of work a week. I'll do this for a few years and pay down debts while I figure out what I want to do when I grow up.

There are two good ways I have found to really push the envelope financially. Find jobs outside of your full time job where they can get paid as a contractor w/o benefits. That is pretty obvious. Also, look to practice positions where professionals shirk away from like corrections.

 

[clausewitz2]

Won't happen. No one wants to get unnecessarily biopsied. You are paying for the knowledge to identify risks effectively. Every derm I know has a great clinic.

Mmkay, there is more than one derm private practice in my current area where NPs see a substantial majority of the patients and the rest ate generally biopsy-happy in the extreme. Maybe licensing laws and the culture of practice are different where you are, but as an existence proof, it rather suggests it is not impossible.

 

[klake3]

I have to laugh at the whole is psych the new derm/rad/optho whatever in terms of competitiveness. I like psych myself, but one only needs to read the "how to increase security in my clinic" thread to understand why psych will never be THAT competitive.

 

[notdeadyet]

Only on SDN can one of the lower paying and least competitive specialties become "the next derm" for reimbursement and send great applicants worried they will match anywhere in the country...

 

[W19]

I'm curious how people are pulling salaries >250K. It'd help us figure out ways to efficiently earn more money.

My VA job right now salaries me at 220K with no call or weekends. With my additional board cert, I'll be at 230K. With bonuses, which are easily accessible, that'll be 245K (I see people talk about the VA a lot but no one mentions the bonus structure which basically is just easy money). I work four 10's at the VA. On my day off, I work a prison gig (good money) or do forensic evals (poor money but intellectually satisfying) for the state. That puts me around 300k for about 50 hours of work a week. I'll do this for a few years and pay down debts while I figure out what I want to do when I grow up.

There are two good ways I have found to really push the envelope financially. Find jobs outside of your full time job where they can get paid as a contractor w/o benefits. That is pretty obvious. Also, look to practice positions where professionals shirk away from like corrections.

I am years away from becoming an attending and this is exactly the way I would want to structure my schedule when I become an attending... A FT job for 4 days/wk and another gig on the side so I can at least bring home 5.5k+/bi-weekly (after taxes, 401k and health insurance) in order to pay off quickly my outrageous student loan. Good to know it is somewhat achievable!

 

[notdeadyet]

If you are really debt-averse, you should consider moonlighting during residency to start nibbling down your debt burden. Depending on program and locale, if you are willing to work hard and make some sacrifices, you can earn your residency salary again via moonlighting.

 

[FlowRate]

It's interesting to see the range of pay for moonlighting at different programs. I've seen from $90/hr to $200/hr.

 

[yanks26dmb]

It's interesting to see the range of pay for moonlighting at different programs. I've seen from $90/hr to $200/hr.

Lets take the middle of those two numbers; $140. How hard would it be to land something like that for 20-30 hours a week as an attending? What I'm saying is...could I take a standard 40 hour a week psych job at 180k, add on another 25 hours a week at $150, and bring home ~360k a year by working 60-65 hours a week?

 

[FlowRate]

Lets take the middle of those two numbers; $140. How hard would it be to land something like that for 20-30 hours a week as an attending? What I'm saying is...could I take a standard 40 hour a week psych job at 180k, add on another 25 hours a week at $150, and bring home ~360k a year by working 60-65 hours a week?

In exchange for your saturdays and sundays and potentially at odd hours, I'd wager it's possible (that's when most of those moonlighting opportunities happen.)

 

[yanks26dmb]

In exchange for your saturdays and sundays and potentially at odd hours, I'd wager it's possible (that's when most of those moonlighting opportunities happen.)

Are you aware of 24 hr gigs in psych, similar to EM or hospitalists?

I'd be nice to work a few 24 hours a week and call it a day...

 

[notdeadyet]

Are you aware of 24 hr gigs in psych, similar to EM or hospitalists?

You will see this more commonly in contractor positions than full-time positions

I work in a psych ER that has people working eight hours during the day on an inpatient psych unit followed by an overnight psych ER shift.

In another psych ER I work in, people frequently string together a series of 16 hour shift. These people are staff psychiatrists. I have not seen the staff members there working a 24 hour shift as part of their schedule.

I wouldn't recommend planning on doing 24 hour psych ER shifts as a career path. Most of the places I have worked, the overnight shift is the busiest. Occasionally you may have a quiet night, but for the most part you are running pretty ragged and eager to get out of there in the morning.

Tired docs in a psych ER is not a good thing. Do it regularly, and you will dramatically increase the likelihood of your patient for yourself having a bad outcome.


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[F0nzie]

Only on SDN can one of the lower paying and least competitive specialties become "the next derm" for reimbursement and send great applicants worried they will match anywhere in the country...

It's entertainment!

 

[yanks26dmb]

You will see this more commonly in contractor positions than full-time positions

I work in a psych ER that has people working eight hours during the day on an inpatient psych unit followed by an overnight psych ER shift.

In another psych ER I work in, people frequently string together a series of 16 hour shift. These people are staff psychiatrists. I have not seen the staff members there working a 24 hour shift as part of their schedule.

I wouldn't recommend planning on doing 24 hour psych ER shifts as a career path. Most of the places I have worked, the overnight shift is the busiest. Occasionally you may have a quiet night, but for the most part you are running pretty ragged and eager to get out of there in the morning.

Tired docs in a psych ER is not a good thing. Do it regularly, and you will dramatically increase the likelihood of your patient for yourself having a bad outcome.


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Thanks for the info. I'll definitely keep those things in mind.

yeah perhaps 24 hours shifts as a full-time career isn't a great choice...but one 24 hour shift a few times a month at $ ___ per hour (do you have any idea?) seems like it could be a pretty good way for the right kind of person to bump their salary nicely.

 

[notdeadyet]

The 24 hour shift would come to about $4k as a contractor. But you probably won't do it long before you burn out.


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[Doctor Bagel]

More salary data from an SDN user:

I work for the state of CA, seeing prisoners in an "outpatient" setting. I work four 10 hour days per week, and see around 10-12 patients per day. I am on phone call one night every 6-8 weeks (never have to go in person; usually get 8-15 calls/night, mostly to renew or hold meds). I live in a large, desirable city. My salary is $285,000

 

[Doctor Bagel]

So new events in my community -- we're merging a few hospital systems to open a new free standing psych hospital with a psychiatric ED. I've moved to a full-time position at a hospital that is merging into this system, meaning my current job will cease to exist maybe by the end of 2016. All nursing staff will be employed by one hospital system that is merging in and all physicians will be employed by the university program. I saw a job listing for the university program for an inpatient psychiatrist, noting that this job will transfer to the new hospital, advertising a salary of $190 to $210k/year. I'm guessing this is no call/good benefits/letting the residents do a lot of your work, etc. type of thing. Seems low for inpatient, though. Definitely less than I'm making, but I'm doing call, etc.. Thoughts? They're going to need a hire a lot of people (or maybe just a lot of nurse practitioners, who knows), and I can't see a lot of people signing up for inpatient work with that pay even with the so-called prestige of an academic job. At least the VA has a good student loan repayment package .... Admittedly I'm an eeyore, but I worry about there being one main employer for inpatient work in the city.

 

[nexus73]

Lack of competition is not good for salaries. Seems like an antitrust issue.

 

[Doctor Bagel]

Lack of competition is not good for salaries. Seems like an antitrust issue.

Well, I doubt it would rise to the level where you could make any sort of legal claim, but yeah, I do worry that it will be a bad thing for employees. It's good to have options with employers. I'm wondering if nursing staff is worried about this, too -- they're unionized, though, so maybe that gives them more protection. This place could be a good thing, but I can't see expecting psychiatrists to take significant pay cuts to work there.

 

[notdeadyet]

$190K-210K for a faculty position wouldn't be too low for California, even with an inpatient bump. Is the fact that you'll be supervising residents a sure thing? Sometimes there are folks working inpatient who just carry an inpatient load as if the residents aren't there, with other positions to handle a mix of carrying your own patients and supervising residents. Can you work this into your contract?

And will they be honoring your seniority from the perspective of benefits, or will you be staring as a Day 1 psychiatrist post-merger.

Incidentally, I've been less than blown away by the VA loan repayment package. When you pull back the covers a bit, the funding allocated for the $120K is region-by-region and is limited. One place I looked at indicated that I likely wouldn't be able to get it.

 

[Doctor Bagel]

$190K-210K for a faculty position wouldn't be too low for California, even with an inpatient bump. Is the fact that you'll be supervising residents a sure thing? Sometimes there are folks working inpatient who just carry an inpatient load as if the residents aren't there, with other positions to handle a mix of carrying your own patients and supervising residents. Can you work this into your contract?

And will they be honoring your seniority from the perspective of benefits, or will you be staring as a Day 1 psychiatrist post-merger.

Incidentally, I've been less than blown away by the VA loan repayment package. When you pull back the covers a bit, the funding allocated for the $120K is region-by-region and is limited. One place I looked at indicated that I likely wouldn't be able to get it.

There are a ton of questions about this whole thing that I don't have answers to. Supposedly the nurses know that they get to keep benefits and seniority. I haven't heard anything with physicians though. I've heard doctors from one system aren't going to transfer over, and I'm wondering what's up with that. And yeah, there will be may more beds than can be managed by the residents, so not all the attendings can have a traditional academic type of job where manage cases with residents rather than independently.

I'm not personally sure of the value of a faculty position -- why is it worth a pay cut if you're not specifically drawn to academic type of work? What am I missing? That's why it's worrisome that multiple employers are all feeding into an academic system.

That's interesting about the VA. I assumed all attendings would qualify.

 

[notdeadyet]

I'm not personally sure of the value of a faculty position -- why is it worth a pay cut if you're not specifically drawn to academic type of work?

I don't think that it is. The pay cut for academia is acceptable only because you're drawn to academia. The opportunity for research, teaching being a big part of your life, cutting edge this/that, etc.

If someone isn't drawn in by that, academia would be a tough sell. It tends to be lower pay and more hours.

That's why it's worrisome that multiple employers are all feeding into an academic system.

I'd agree. There is the potential for having Acme Academics and swallowing up lots of different systems, then giving everyone an academic title in name only and potentially getting away with underpaying. All animals are equal but some are more equal than others type of thing.

That's interesting about the VA. I assumed all attendings would qualify.

All attending do qualify. It's just a matter of whether or not the funding is available. I've heard a lot of VA systems prioritize the CBOCs and hard-to-fill positions.

 

[Doctor Bagel]

I'd agree. There is the potential for having Acme Academics and swallowing up lots of different systems, then giving everyone an academic title in name only and potentially getting away with underpaying. All animals are equal but some are more equal than others type of thing.

All attending do qualify. It's just a matter of whether or not the funding is available. I've heard a lot of VA systems prioritize the CBOCs and hard-to-fill positions.

My cynical thoughts are that they're going to fill the positions with new grads who don't know to ask for more money (hey, $190k is a lot more than $62k) and/or NPs coupled with relying on moonlighting residents to cover nights and weekends while paying less than other systems would pay them because there are no inpatient higher pay moonlighting jobs for residents in this town.

VA hiring seems so weird anyway -- you've got to wait so long for a position to be approved/posted/closed. Getting my data compromised in their breach (just received notice of this recently) has also soured me a little on the VA.

 

[notdeadyet]

Getting my data compromised in their breach (just received notice of this recently) has also soured me a little on the VA.

It improves with time and repetition. My military security clearance forms describing every place I've lived, every country I've traveled to, the names and contact info of many of my close friends, every drug I've tried and every brush I've ever had with the law is sitting in a file cabinet in some government office in China. That's in addition to my social security number, name and DOB, being compromised at least once a year per emails I get letting me know that SGT Snuffy got a military laptop stolen from the cab of his pick-up outside of a Hooters.

Edit: I'm editorializing a bit. But sadly not sensationalizing...

 

[clausewitz2]

So new events in my community -- we're merging a few hospital systems to open a new free standing psych hospital with a psychiatric ED. I've moved to a full-time position at a hospital that is merging into this system, meaning my current job will cease to exist maybe by the end of 2016. All nursing staff will be employed by one hospital system that is merging in and all physicians will be employed by the university program. I saw a job listing for the university program for an inpatient psychiatrist, noting that this job will transfer to the new hospital, advertising a salary of $190 to $210k/year. I'm guessing this is no call/good benefits/letting the residents do a lot of your work, etc. type of thing. Seems low for inpatient, though. Definitely less than I'm making, but I'm doing call, etc.. Thoughts? They're going to need a hire a lot of people (or maybe just a lot of nurse practitioners, who knows), and I can't see a lot of people signing up for inpatient work with that pay even with the so-called prestige of an academic job. At least the VA has a good student loan repayment package .... Admittedly I'm an eeyore, but I worry about there being one main employer for inpatient work in the city.

They are telling applicants that only one unit of ~20 beds is going to have regularly assigned residents. So not all of the attending jobs will have someone covering grunt work. Also, they seem to believe that there will be no residents regularly on call there, so yeah, either they are counting on moonlighters or somebody is being hired for those units.

 

[Doctor Bagel]

They are telling applicants that only one unit of ~20 beds is going to have regularly assigned residents. So not all of the attending jobs will have someone covering grunt work. Also, they seem to believe that there will be no residents regularly on call there, so yeah, either they are counting on moonlighters or somebody is being hired for those units.

Are residents going to do overnight shift work in the emergency department?

Anyway, it makes everything feel chaotic right now in that it's hard to invest in current systems when you've got this big new system coming. Seriously this is a great spot for locums type of stuff right now while everything is getting sorted out. I wish I had a little more clarity about how the sorting out will go, though. I guess if salaries drop, that's a sign I should do private practice instead.

 

[nexus73]

Could create an incentive to form a doctor's union. Will the university be employing everyone?

 

[clausewitz2]

Are residents going to do overnight shift work in the emergency department?

The plan seemed a bit hazy and may not have been totally finalized yet, but I -think so-? During the day it was made clear they would be confined to the Teaching Ward.

 

[Blitz2006]

Sorry guys if I was misleading. Psych can never match the volume, procedural abilities, and income potential that Derm has. With the right payor mix and volume, Derm can make over $1 Mill per year. I think what I was referring to was that the special group of higher Psych earners - those who can see a full day of patients and earn handsome rates in cities like New York City, Palo Alto, Boston, and Los Angeles - can match the average salary of a non-Mohs, general dermatologist. We're talking $350 - $400K. That's how I was comparing it, but should have explained a bit more. At the same token, Derm is not what it once was either.

Totally agree, and I'm surprised more people haven't commented on this.

I personally think its very impressive, that a "low tier" specialty can "match the average salary of" god almighty Derm (Non-Mohs). If this info leaks into the real world, watch out .

I was told by an attending that salary at a particular group practice setting in midtown Manhattan is 205K (no benefits, no-call, 9-5 M-F). After a few years, build up clientele and swing into solo practice and do some cash only, and you are in the 350k range by the age of 40.

This is one thing medical students should pay more attention to. That psychiatry is one of the few specialties where your income can potentially GO UP in a large metropolitan area. And the job market is ripe in NYC even with this perk.

 

[keifernny2]

There does appear to be a disconnect between salaries, reimbursement, and productivity.

I've seen a number of positions with a salary model where new attending billings appear subsidize more senior attending that have a low productivity. I often wonder why there aren't more production-based positions advertised with salary guarantee in psychiatry. ie: I would assume, even with lower reimbursements, that a provider in a medicaid clinic who sees 4pts /hr would often be billing more $$/hr than the private practice doc that sees 2/hr. Is is just that people attracted to these jobs aren't as financially minded to notice this, or is it that other, non-billing clinic admin staff in large medicaid clinics are taking so much $$ from the system that they end up losing money?

 

[TexasPhysician]

There does appear to be a disconnect between salaries, reimbursement, and productivity.

I've seen a number of positions with a salary model where new attending billings appear subsidize more senior attending that have a low productivity. I often wonder why there aren't more production-based positions advertised with salary guarantee in psychiatry. ie: I would assume, even with lower reimbursements, that a provider in a medicaid clinic who sees 4pts /hr would often be billing more $$/hr than the private practice doc that sees 2/hr. Is is just that people attracted to these jobs aren't as financially minded to notice this, or is it that other, non-billing clinic admin staff in large medicaid clinics are taking so much $$ from the system that they end up losing money?

Medicaid rates are so low that you need more than 4 Medicaid patients to reach the earnings of 2 in my private practice and that is not including added expenses and awful show rates.

 

[keifernny2]

Medicaid rates are so low that you need more than 4 Medicaid patients to reach the earnings of 2 in my private practice and that is not including added expenses and awful show rates.

I hear you on the private practice comparison, but in some states FQHC clinics are reimbursed at higher rates than PP medicaid physicians and also the large clinics can run a walk in and overbook clinic that reduces the hit from no shows. Those are things I'd honestly never be willing to do in a private practice . I guess it really depends on the reimbursement for that particular facility.


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[prominence]

What's a realistic expectation for the maximum base salary for a salaried (non-contractor status) board certified adult psychiatrist (who does not see any child and adolescent pts) working 40 hours per week? I'm guessing $295k (likely inpatient psychiatry setting). Any thoughts?

 

[PistolPete]

The highest I've seen is about $290k for corrections or state hospitals after about 3-5 years worked.

 

[Doctor Bagel]

What's a realistic expectation for the maximum base salary for a salaried (non-contractor status) board certified adult psychiatrist (who does not see any child and adolescent pts) working 40 hours per week? I'm guessing $295k (likely inpatient psychiatry setting). Any thoughts?

From my experience, to get that much for inpatient, you need to do a decent amount of call as well. Or maybe be in an undesirable area.

 

[notdeadyet]

From my experience, to get that much for inpatient, you need to do a decent amount of call as well. Or maybe be in an undesirable area.

I agree. If you're wrong, then I'm definitely peeking under the wrong rocks. I haven't seen inpatient jobs anywhere near that in California.

The highest starting pay jobs I've seen out my way have been Kaiser, which were offering well below that. Even the prison system, which tends to pay really well out here, starts at about $240K.

 

[F0nzie]

I agree. If you're wrong, then I'm definitely peeking under the wrong rocks. I haven't seen inpatient jobs anywhere near that in California.

The highest starting pay jobs I've seen out my way have been Kaiser, which were offering well below that. Even the prison system, which tends to pay really well out here, starts at about $240K.

These threads always make me feel like I am peeking under the wrong rocks!

 

[sunlioness]

It's like the people who pm me asking "how can I make oodles of money working in a major metro for forty hours a week with no call?" And I'm like, I don't know. But if you figure it out, tell me.


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[nexus73]

It's like the people who pm me asking "how can I make oodles of money working in a major metro for forty hours a week with no call?" And I'm like, I don't know. But if you figure it out, tell me.


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What is the psychiatry equivalent of selling out? Suboxone for cash? Adult ADHD clinic for cash?

 

[notdeadyet]

Medical marijuana.

Of course, the problem with a lot of these schemes (aside from the sense of dread/shame you get when you look at yourself when you shave or the female-type equivalent) is that you may be setting yourself up to lose your medical license. In which case you're really hosed.

 

[Trismegistus4]

The administrator at my current locums assignment (which is in an undesirable area) has tried to tempt me to stay permanently by saying I could earn $450k/year. But that would involve rounding every other weekend.

 

[nexus73]

The administrator at my current locums assignment (which is in an undesirable area) has tried to tempt me to stay permanently by saying I could earn $450k/year. But that would involve rounding every other weekend.

define rounding

 

[keifernny2]

The administrator at my current locums assignment (which is in an undesirable area) has tried to tempt me to stay permanently by saying I could earn $450k/year. But that would involve rounding every other weekend.

Making 450k would be great, but if you're rounding every other weekend (and haven't heard how many patients you're seeing on weekdays), Is it possible you are really just doing 2 jobs?

 

[Trismegistus4]

define rounding

Seeing patients, putting in orders, and writing notes.

Making 450k would be great, but if you're rounding every other weekend (and haven't heard how many patients you're seeing on weekdays), Is it possible you are really just doing 2 jobs?

I wouldn't say that. Normally it's up to 12 on weekdays, but if 1 doc is out, the rest can have up to 14. On weekends, the max is 14. Doesn't rise to the level of 2 jobs, IMO.

 

[st2205]

Seeing patients, putting in orders, and writing notes.


I wouldn't say that. Normally it's up to 12 on weekdays, but if 1 doc is out, the rest can have up to 14. On weekends, the max is 14. Doesn't rise to the level of 2 jobs, IMO.

That's doesn't sound too bad unless they've got a very inefficient system.

 

[Doctor Bagel]

That's doesn't sound too bad unless they've got a very inefficient system.

But you're working two full weekends out of four which kinda sucks.

 

[michaelrack]

But you're working two full weekends out of four which kinda sucks.

On the other hand, 250k a year for a STANDARD (if there is such a thing) inpatient job with 1 weekend a month call would be excellent pay. So 450 k for 2 weekends a month would be like getting 200k for rounding 12-14 extra weekends (accounting for months with 5 weekends). seems like a pretty good deal if the whole 450k is guaranteed (not based on meeting bonus targets)

 

[Doctor Bagel]

On the other hand, 250k a year for a STANDARD (if there is such a thing) inpatient job with 1 weekend a month call would be excellent pay. So 450 k for 2 weekends a month would be like getting 200k for rounding 12-14 extra weekends (accounting for months with 5 weekends). seems like a pretty good deal if the whole 450k is guaranteed (not based on meeting bonus targets)

You think? I'd think of $250k/year with one weekend of call as standard pay. Weekend call in my neck of the woods pays $3k to $3.5k or so so that alone is $30 to $40k, leaving you with around $220k/year for base, which seems fair. I have yet to hear of a job in my city excluding academic/VA which has it's own structure that pays less than $100/hour, which would get you to low $200ks for base in either inpatient or outpatient, including community.

 

[Doctor Bagel]

It's interesting to see the range of pay for moonlighting at different programs. I've seen from $90/hr to $200/hr.

In my residency program, there was only one place in town that hired residents, and it paid $68/hour. You could drive an hour or more out of town and earn $3k or more working inpatient weekends. No $200 hour/here. The state where I went to medical school seemed to have much more lucrative moonlighting but yet was also a worse place to live.

 

[notdeadyet]

To get $200/hour moonlighting, I would have to drive three hours to work with people wearing stripes.