Is the market for Psychiatry going down?

[Mad Jack]

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Half of US counties still have zero psychiatrists. Many of the psych-trained NPs in the area I work in don't seem to stick around in any given job for any period of time, and their performance has led to most inpatient units going back to physician-only models. I'm in the Northeast and there's still a good number of jobs available and I still constantly get harassed by recruiters. If you're child trained, there's even more opportunity. I'm not a private practice guy, so can't really comment on that.

I would recommend saving enough money that you're not dependent upon an employer or job as soon as you are able to after residency, because at that point the job market doesn't matter. I could retire before I hit 50 and live quite a nice life at my current rate, and could have no cut in my quality of life if I work to 52. Anything past that is just gravy.

 

[sloh]

This thread on Psychiatry reddit paints an extremely gloomy picture for the job market. Perhaps, they are more pessimistic because the users tend to skew toward younger, hence attendings right out of residency?



What do you think?

Wow this thread is depressing.

 

[joooul]

So... would risk management as med student be to shirk the field entirely?... even if it's the field that excites them the most? 😀

I would definitely choose psychiatry if it were the most exciting field to me. IMHO, focusing on becoming the best doctor possible should address the majority of the manageable risks pertaining to the specialty.

 

[finalpsychyear]

Half of US counties still have zero psychiatrists. Many of the psych-trained NPs in the area I work in don't seem to stick around in any given job for any period of time, and their performance has led to most inpatient units going back to physician-only models. I'm in the Northeast and there's still a good number of jobs available and I still constantly get harassed by recruiters. If you're child trained, there's even more opportunity. I'm not a private practice guy, so can't really comment on that.

I would recommend saving enough money that you're not dependent upon an employer or job as soon as you are able to after residency, because at that point the job market doesn't matter. I could retire before I hit 50 and live quite a nice life at my current rate, and could have no cut in my quality of life if I work to 52. Anything past that is just gravy.

Great advice. This is the key no matter what field you choose. Medicine you have delayed your whole life so at first it seems silly why not buy/lease the new car, get the doctor house, etc. But from a numbers game you are WAAAY behind those working in there early 20s esp those investing already have a decade of compound interest that you never will get.

The main way you win is using your paycheck to try and make up some lost time. People will do this to various degrees. Just had a dinner with some docs friend and their neighbors who are both ER docs retired at 38 yo after both working nights for 8-10 years and investing heavy.... ER has sorta gone down from where it was so those folks took advantage when they could and milked that gravy train.

I've also met docs a few years ago who were content working till 60 yo and now they are like ohh crap they are burned out and want to get out closer to 50 but they were spending and saving assuming work till 60.....

Again, Im wired different. I've always hoped to try and have a goal of being work optional mid 40s if possible since i started this journey and for me it was clearly the best move and i hope more people can get there as well. Def not easy and you have to make sacrifices but don't need to live quite like a resident but maybe somewhere in between for a few years to kickstart things.

 

[randomdoc1]

Great advice. This is the key no matter what field you choose. Medicine you have delayed your whole life so at first it seems silly why not buy/lease the new car, get the doctor house, etc. But from a numbers game you are WAAAY behind those working in there early 20s esp those investing already have a decade of compound interest that you never will get.

The main way you win is using your paycheck to try and make up some lost time. People will do this to various degrees. Just had a dinner with some docs friend and their neighbors who are both ER docs retired at 38 yo after both working nights for 8-10 years and investing heavy.... ER has sorta gone down from where it was so those folks took advantage when they could and milked that gravy train.

I've also met docs a few years ago who were content working till 60 yo and now they are like ohh crap they are burned out and want to get out closer to 50 but they were spending and saving assuming work till 60.....

Again, Im wired different. I've always hoped to try and have a goal of being work optional mid 40s if possible since i started this journey and for me it was clearly the best move and i hope more people can get there as well. Def not easy and you have to make sacrifices but don't need to live quite like a resident but maybe somewhere in between for a few years to kickstart things.

I agree. It's just safer that way. Think of it as insurance. Like a disability insurance. Economy insurance. I've always been neurotic due to experiencing many worst case scenarios. I'm the hoarding type when it comes to finances after all the financial chaos of my family origin. So it's definitely a form of compensating but ended up being constructive as opposed to impairing. And although I was not trying to...I've reached FIRE.

 

[TexasPhysician]

Half of US counties still have zero psychiatrists. Many of the psych-trained NPs in the area I work in don't seem to stick around in any given job for any period of time, and their performance has led to most inpatient units going back to physician-only models. I'm in the Northeast and there's still a good number of jobs available and I still constantly get harassed by recruiters. If you're child trained, there's even more opportunity. I'm not a private practice guy, so can't really comment on that.

I would recommend saving enough money that you're not dependent upon an employer or job as soon as you are able to after residency, because at that point the job market doesn't matter. I could retire before I hit 50 and live quite a nice life at my current rate, and could have no cut in my quality of life if I work to 52. Anything past that is just gravy.

Most USA counties will never need a psychiatrist. They don’t have the population to support one. 90% of counties don’t need a neurosurgeon either.

 

[finalpsychyear]

I agree. It's just safer that way. Think of it as insurance. Like a disability insurance. Economy insurance. I've always been neurotic due to experiencing many worst case scenarios. I'm the hoarding type when it comes to finances after all the financial chaos of my family origin. So it's definitely a form of compensating but ended up being constructive as opposed to impairing. And although I was not trying to...I've reached FIRE.

Also I should point out. It really sucks to be in a position where you are in your 40s and realize you need to work more, harder, or more years than you want.

After 10 years I can already tell you my mental load for work peaked out a few years ago. Similarly I can notice a small decline in physicality meaning i can't quite do the volume/weight of deadlift/pullups what i could just a few years ago but thats maybe not crazy for someone comparing their 30 to 40 yo as thats natural decline.

Hard to quantify if my mental tolerance now is just a factor of age or working more like surgeon hours without the nights, wknds, holidays or sleep deprivation for most of a decade and being very close to work optional mode (financial independence territory). I'm lucky 90% of my patients are stabilized q3-4 month med checks.

 

[Mad Jack]

Most USA counties will never need a psychiatrist. They don’t have the population to support one. 90% of counties don’t need a neurosurgeon either.

These counties have populations that are 25,000 or less, but 25,000 people is plenty to support a singilar psychiatrist, and actually 2.5, statistically. The great majority of them have populations greater than 10,000, and given that the WHO recommendation is 1 psychiatrist per 10,000 population, there's clearly a need. Psychiatrists aren't like neurosurgeons- they need a ratio of 1:100,000 to support.

Who wants to live there is an entirely separate question, but there is a need

 

[comp1]

The counties could definitely support a psychiatrist. A psychiatrist doesn't want to support the counties, which is often unfortunately understandable. The market is still there!

 

[FatherPsychiatry]

Psychiatric mental health nurse practitioners in transition: A descriptive analysis of workforce trends and dual preparation in primary care, 2016-2024 - PubMed

PMHNPs can increasingly help to meet population health needs for behavioral health care as shortages of psychiatrists and psychologists worsen. Policy makers should ensure they are easy for patients to access by supporting measures that support telehealth and rural and independent practice.

pubmed.ncbi.nlm.nih.gov

Summarized by Chris Aiken, MD , the chief editor of the Carlat Psychiatry Report:

Changes in Psychiatric NPs since 2016:

▪ Visits doubled for PMH-NPs, fell by 30% for psychiatrists
▪ 12% run their own practice
▪ Non-whites increased 8% to 16%
▪ DNPs rose 13% to 26%, and 41% are dual-certified

Dr. Aiken: "I provide #PMHNP consultation, and supervision in NJ, VA, NC, SC, GA, FL"

 

[finalpsychyear]

Psychiatric mental health nurse practitioners in transition: A descriptive analysis of workforce trends and dual preparation in primary care, 2016-2024 - PubMed

PMHNPs can increasingly help to meet population health needs for behavioral health care as shortages of psychiatrists and psychologists worsen. Policy makers should ensure they are easy for patients to access by supporting measures that support telehealth and rural and independent practice.

pubmed.ncbi.nlm.nih.gov

Summarized by Chris Aiken, MD , the chief editor of the Carlat Psychiatry Report:

Changes in Psychiatric NPs since 2016:

▪ Visits doubled for PMH-NPs, fell by 30% for psychiatrists
▪ 12% run their own practice
▪ Non-whites increased 8% to 16%
▪ DNPs rose 13% to 26%, and 41% are dual-certified

Dr. Aiken: "I provide #PMHNP consultation, and supervision in NJ, VA, NC, SC, GA, FL"

You also have upcoming PA and more and more NPs. Expect this trend to continue there's nothign else to say about that. All fields usually have an upswing like i feel there was a pretty sweet run in psych the last 10-12 years but then a huge influx of mid levels everywhere. Maybe happened slightly faster than i had hoped.

Not saying you can't get a good job still but def a decline in some ways. There are still a lot of 250-350k jobs around but you will likely be supervising mulitple mid levels as part of that. Also, expect more states to give full autonomy in the next 5 years which is around the time i would love to be in a work optional or part time mode if possible. If i were in med school i would only be interested in surgical or well protected procedural fields i.e. cards/gi/hem onc

This still saddens me to see this a bit but its been a driver of mine since getting out that this was likely to come and part of the reason i work extra hard for 10 years now and try and save and invest till it hurts. Like no double chicken levels of sacrifice 🤣

 

[TexasPhysician]

The counties could definitely support a psychiatrist. A psychiatrist doesn't want to support the counties, which is often unfortunately understandable. The market is still there!

Would be nice if true. I’ve actually been trying to build a more rural practice. Demand is incredibly low despite no other psychiatrist around. I’m just a n-1. You could argue that the population is large enough and the % of mental illness should support one. Downside is that the areas are so accustomed to not having a psychiatrist that things need to be much worse before anyone takes a step toward care. Very different mentality. It is hard to build a referral net when there is almost no other clinicians around.

Even if the population should support a psychiatrist, the time needed for everyone to either transfer care or acknowledge mental illness is a long period of time. Expect a much larger build time that most psychiatrists won’t accept.

 

[FlowRate]

Psychiatric mental health nurse practitioners in transition: A descriptive analysis of workforce trends and dual preparation in primary care, 2016-2024 - PubMed

PMHNPs can increasingly help to meet population health needs for behavioral health care as shortages of psychiatrists and psychologists worsen. Policy makers should ensure they are easy for patients to access by supporting measures that support telehealth and rural and independent practice.

pubmed.ncbi.nlm.nih.gov

Summarized by Chris Aiken, MD , the chief editor of the Carlat Psychiatry Report:

Changes in Psychiatric NPs since 2016:

▪ Visits doubled for PMH-NPs, fell by 30% for psychiatrists
▪ 12% run their own practice
▪ Non-whites increased 8% to 16%
▪ DNPs rose 13% to 26%, and 41% are dual-certified

Dr. Aiken: "I provide #PMHNP consultation, and supervision in NJ, VA, NC, SC, GA, FL"

From the abstract: "PMHNPs can increasingly help to meet population health needs for behavioral health care as shortages of psychiatrists and psychologists worsen. Policy makers should ensure they are easy for patients to access by supporting measures that support telehealth and rural and independent practice."

I don't follow how NP's replace psychologists, but I guess they can really do anything and everything anyone else in the BH space can do, and just as well... /s

 

[comp1]

Some NPs are pretty good at psychotherapy and even prefer doing it. Their training can be highly variable. Some definitely have more psychotherapy training than the average psychiatrist, although much less on average of course. In terms of the rural market, I agree that if you set out to launch a private practice, it's going to be super hard. What I meant is that institutions (VA, HMOs, etc) are hiring rurally. However, building a whole network of referrals yourself through things like insurance paneling is going to be very hard and definitely is not something I would recommend.

 

[Stagg737]

You also have upcoming PA and more and more NPs. Expect this trend to continue there's nothign else to say about that. All fields usually have an upswing like i feel there was a pretty sweet run in psych the last 10-12 years but then a huge influx of mid levels everywhere. Maybe happened slightly faster than i had hoped.

Not saying you can't get a good job still but def a decline in some ways. There are still a lot of 250-350k jobs around but you will likely be supervising mulitple mid levels as part of that. Also, expect more states to give full autonomy in the next 5 years which is around the time i would love to be in a work optional or part time mode if possible. If i were in med school i would only be interested in surgical or well protected procedural fields i.e. cards/gi/hem onc

This still saddens me to see this a bit but its been a driver of mine since getting out that this was likely to come and part of the reason i work extra hard for 10 years now and try and save and invest till it hurts. Like no double chicken levels of sacrifice 🤣

On the flip side, I heard this exact argument from all the docs I shadowed when I was pre-med back around 2008-10. I kept hearing that it was good I liked ortho because there would be no PCPs in 10 years because NPs would be taking all those jobs or there'd barely be any because of all the NPs FM docs would be supervising. There's still plenty of PCPs. They're still making a (generally) solid salary. Some of them make great money in niches they've carved out (DPC, rural/procedural, etc). NPs have changed the landscape somewhat, but almost 20 years later we're all still here. I work in a state where NPs were given autonomy ~5 years ago, pretty much nothing has changed.

Could things change? Sure, but mid-levels aren't going to be the swan song of psychiatry in the next 5-10 years. Progress is slow and cumbersome and often twists and turns in unpredictable directions, usually ones that impede progress. It's the same reason why I don't see AI bringing an earth-shattering revolution that completely upends our field in the next 5-10 years like many people think it will be.

 

[shoomer]

On the flip side, I heard this exact argument from all the docs I shadowed when I was pre-med back around 2008-10. I kept hearing that it was good I liked ortho because there would be no PCPs in 10 years because NPs would be taking all those jobs or there'd barely be any because of all the NPs FM docs would be supervising. There's still plenty of PCPs. They're still making a (generally) solid salary. Some of them make great money in niches they've carved out (DPC, rural/procedural, etc). NPs have changed the landscape somewhat, but almost 20 years later we're all still here. I work in a state where NPs were given autonomy ~5 years ago, pretty much nothing has changed.

Could things change? Sure, but mid-levels aren't going to be the swan song of psychiatry in the next 5-10 years. Progress is slow and cumbersome and often twists and turns in unpredictable directions, usually ones that impede progress. It's the same reason why I don't see AI bringing an earth-shattering revolution that completely upends our field in the next 5-10 years like many people think it will be.

I agree that doomerism is overstated, but psychiatry does offer a more desirable and (seemingly) less difficult field than primary care to aspiring NPs. Midlevels have changed the landscape of emergency medicine dramatically so there is some precedent, although psychiatry is of course far less susceptible to the issues plaguing EM.

I don't think psychiatry will be in shambles, but I do think psychiatrists are going to have to be more creative in finding niches, train & specialize more, and will have to work harder for the same or less reward. This will be especially true in more desirable places. Which is a far cry from what I constantly heard in training about how amazing the market was for us.

 

[Stagg737]

I agree that doomerism is overstated, but psychiatry does offer a more desirable and (seemingly) less difficult field than primary care to aspiring NPs. Midlevels have changed the landscape of emergency medicine dramatically so there is some precedent, although psychiatry is of course far less susceptible to the issues plaguing EM.

I don't think psychiatry will be in shambles, but I do think psychiatrists are going to have to be more creative in finding niches, train & specialize more, and will have to work harder for the same or less reward. This will be especially true in more desirable places. Which is a far cry from what I constantly heard in training about how amazing the market was for us.

I think it's also important to keep in mind that a lot of old docs telling residents how great the market is (including high salaries) are going to have multiple biases. PP salary probably sounds incredible for those academic attendings who have spent their whole careers in the ivory tower making a fraction of what PP docs make. I also think a lot of older psychiatrists remember the days when they weren't coming close to touching surgery pay, but today it's very possible for psychiatrists to have similar salaries to surgeons outside of the really high paying sub-specialties. The idea that there is a bit more parity between specialties is something I think a lot of older docs feel is great while younger docs expect this without realizing how it used to be. I think there's probably a significant disparity in opinions on what "good pay" means as well as an ignorance that there's some saturation in really desirable areas as well as a lack of flexibility in younger generations about where they're willing to practice.

 

[Mad Jack]

Psychiatric mental health nurse practitioners in transition: A descriptive analysis of workforce trends and dual preparation in primary care, 2016-2024 - PubMed

PMHNPs can increasingly help to meet population health needs for behavioral health care as shortages of psychiatrists and psychologists worsen. Policy makers should ensure they are easy for patients to access by supporting measures that support telehealth and rural and independent practice.

pubmed.ncbi.nlm.nih.gov

Summarized by Chris Aiken, MD , the chief editor of the Carlat Psychiatry Report:

Changes in Psychiatric NPs since 2016:

▪ Visits doubled for PMH-NPs, fell by 30% for psychiatrists
▪ 12% run their own practice
▪ Non-whites increased 8% to 16%
▪ DNPs rose 13% to 26%, and 41% are dual-certified

Dr. Aiken: "I provide #PMHNP consultation, and supervision in NJ, VA, NC, SC, GA, FL"

If you look at the paper, that "30% drop" is not a true 30% decline in psychiatrist appointments, but rather a 30% decline in the number of medicare beneficiaries seen by psychiatrists between 2011 and 2019, as derived from this paper: Trends In Mental Health Care Delivery By Psychiatrists And Nurse Practitioners In Medicare, 2011-19 - PMC

Psychiatrists have stopped seeing Medicare benificiaries because Medicare doesn't pay, not because NPs are stealing their business.

 

[J ROD]

The money is there and the opportunity but you have to work to get paid. I make bank but I work multiple jobs and work about 70 hours per week. Mostly from home. It took me quite the time to find the right mix of jobs and employers I like (pay, treat you right). Done several jobs I was not in love with but they helped me keep things rolling until I could find exactly what I wanted. Both of my parents worked labor intensive jobs and similar hours to what I work. They did this for 50 plus years each. I sit on my butt and talk to people and type all day. Make great money I think for the work I do compared to others that are out there doing labor and physical work.

 

[psydocc]

From the abstract: "PMHNPs can increasingly help to meet population health needs for behavioral health care as shortages of psychiatrists and psychologists worsen. Policy makers should ensure they are easy for patients to access by supporting measures that support telehealth and rural and independent practice."

I don't follow how NP's replace psychologists, but I guess they can really do anything and everything anyone else in the BH space can do, and just as well... /s

NPs will proclaim themselves to be the supreme masters of all specialities of medicine and science past, present, and future... and then they wonder why most physicians view them as a bunch of clowns.

 

[hallowmann]

I think that:

1. None of these kids know how to look for a job. Notice several people coming in saying the solid jobs aren’t advertised. Ime that’s 99% accurate, good jobs don’t need extensive advertising and if you want to find a great job you either need to make connections or spend more than 5 minutes on the Google. People who spent time in the real world working instead of just being students annd residents until they’re 30 know this.

2. Everyone on that thread seems to want to find inpatient jobs in the most desirable/popular metros. When you’re only willing to work a specific type of job in a specific major city then you’ve got to expect competition. This is basic supply and demand not rocket science.

3. They expect a great job to just be waiting for them where they’ll make bank with minimal work. Making bank requires you to grind volume, take the time to build something, or be knowledgeable and flexible enough to offer a unique service. I’ve noticed in the past 3-5 years residents seem to feel almost entitled to the lifestyle and expect whatever job they want to be waiting for them. There are plenty of great opportunities, it just may not be doing exactly what you want, exactly where you want, as soon as you want.

So yea, I can see why that thread is so full of gloom. And yes, there are specific places where the job market is just not great, but overall that thread is more of a reflection of naivety of the posters than the actual job market.

I think it's worth pointing out that they are also coming into an environment that honestly looks so much worse than when they started med school or even residency. Inflation in all necessities (mainly looking at food, but honestly almost everything) and housing costs are just staggering, compared to even 4 yrs ago let alone 6-8. At least part of how they feel is from that.

That all said, yes I agree we are still doing better than most. All my IT friends are honestly struggling right now with huge upheavals in their companies, and this is ranging from people in relatively small "mom and pop" startups to huge international companies. That's to say nothing of my young patients that are struggling to find any job anywhere.

 

[Stagg737]

I think it's worth pointing out that they are also coming into an environment that honestly looks so much worse than when they started med school or even residency. Inflation in all necessities (mainly looking at food, but honestly almost everything) and housing costs are just staggering, compared to even 4 yrs ago let alone 6-8. At least part of how they feel is from that.

That all said, yes I agree we are still doing better than most. All my IT friends are honestly struggling right now with huge upheavals in their companies, and this is ranging from people in relatively small "mom and pop" startups to huge international companies. That's to say nothing of my young patients that are struggling to find any job anywhere.

Sure, but that thread is just about job opportunities and mostly people complaining that they can’t find an inpatient job in high demand cities that pays $400k. I get the expense side is more difficult, especially in (V)HCoL locales, but that’s not really what people were upset about.

And yep, we still have it way better than many industries. I have a couple of patients who were making 6 figures in IT working remotely and now can’t find any job. My spouse was in advertising and got let go when here company laid off 40% of their employees. She spent 9 months looking for jobs in advertising and marketing and every job had 200-300 applicants per position. She pivoted to teaching of all things, which pays a lot less but at least there’s work (and decent benefits).

 

[zolof]

It really depends on what kind of practice. In office vs telemed is another example of saturation. Have you seen instagram, facebook, tiktok, etc, there is an explosion of ads featuring many NPs or PAs that market themselves all over for telepsychiatry, some in multiple states . Whethere they are full or sustaining a full time practice at all is another thing.

 

[comp1]

Just the very idea any part of a practice could be from home represents such a massive shift for our field. I saw absolutely nothing of it in med school and even by residency telepsych was considered "research." When I started my attending job there was occasionally a push to make attempts at deploying it (which didn't happen). COVID, and all of a sudden, it was standard of care. Just the possibility represents a huge improvement in the QOL for our field. I guess that it's not something you can really appreciate as a recent grad, but seriously, it's new. Beyond saying, well, we have it better than IT...I think it's important to seriously recognize and appreciate that we have it actually darn good compared to the VAST majority of jobs, inside or outside of medicine. Remember that with the wealth disparity in the US, the top 10% keeps getting better and, check the math, we are squarely in the middle of that.

 

[clausewitz2]

Just the very idea any part of a practice could be from home represents such a massive shift for our field. I saw absolutely nothing of it in med school and even by residency telepsych was considered "research." When I started my attending job there was occasionally a push to make attempts at deploying it (which didn't happen). COVID, and all of a sudden, it was standard of care. Just the possibility represents a huge improvement in the QOL for our field. I guess that it's not something you can really appreciate as a recent grad, but seriously, it's new. Beyond just saying, well, we have it better than IT...I think it's important to seriously recognize and appreciate that we have it actually darn good compared to the VAST majority of jobs, inside or outside of medicine. Remember that with the wealth disparity in the US, the top 10% keeps getting better and, check the math, we are squarely in the middle of that.

I have several patients who are relatively high-powered attorneys. At intake I asked one of them what he did for a living. He told me he practiced law and I asked how it was going for him. He paused, and then said "You ever see that song from Crazy Ex-Girlfriend? 'Don't Be a Lawyer?' Yeah. Basically that."

 

[TexasMed22]

You also have upcoming PA and more and more NPs. Expect this trend to continue there's nothign else to say about that. All fields usually have an upswing like i feel there was a pretty sweet run in psych the last 10-12 years but then a huge influx of mid levels everywhere. Maybe happened slightly faster than i had hoped.

Not saying you can't get a good job still but def a decline in some ways. There are still a lot of 250-350k jobs around but you will likely be supervising mulitple mid levels as part of that. Also, expect more states to give full autonomy in the next 5 years which is around the time i would love to be in a work optional or part time mode if possible. If i were in med school i would only be interested in surgical or well protected procedural fields i.e. cards/gi/hem onc

This still saddens me to see this a bit but its been a driver of mine since getting out that this was likely to come and part of the reason i work extra hard for 10 years now and try and save and invest till it hurts. Like no double chicken levels of sacrifice 🤣

Not sure I would call onc or cards well protected. Half the notes I see from those specialties are written by midlevels

 

[splik]

Not sure I would call onc or cards well protected. Half the notes I see from those specialties are written by midlevels

Midlevels in those specialties are not practicing or functioning in the same way as they are in psych or primary care. In psychiatry we are seeing them used interchangeably or where there's no physician at all. That is just not the case in oncology, cards, neurology etc. They are used in a way that allows physicians to focus on more complex revenue generating activities. When I worked in neurology, the NPs would do things like refills, follow ups for stable pts, answer inbox messages for patients, do scheduled H&P admissions while the neurologists, schedule pts for admission to the epilepsy monitoring unit, do the discharge summaries etc. They weren't seeing new pts, reading EEGs, doing RNS/VNS/DNS programming etc.

 

[Merovinge]

Midlevels in those specialties are not practicing or functioning in the same way as they are in psych or primary care. In psychiatry we are seeing them used interchangeably or where there's no physician at all. That is just not the case in oncology, cards, neurology etc. They are used in a way that allows physicians to focus on more complex revenue generating activities. When I worked in neurology, the NPs would do things like refills, follow ups for stable pts, answer inbox messages for patients, do scheduled H&P admissions while the neurologists, schedule pts for admission to the epilepsy monitoring unit, do the discharge summaries etc. They weren't seeing new pts, reading EEGs, doing RNS/VNS/DNS programming etc.

This is definitely more system and location dependent than this description. When my partner and I used to work in a rural health care system we had endless jokes about the NP consults that would be placed for the medical subspecialities. The NPs would literally copy/paste notes that were minimally altered/personalized towards the patient. The nephrology ones would have some comments about limiting NSAIDs and contrast for every patient. Cards would have similar comical statements.

I am sure there are plenty of places where subspecialists NPs are doing what you describe, but there are plenty where they are not. We are even seeing places where NPs are doing surgical procedures (of course not all cases, but real cases with real risks) without direct MD supervision in the same way anesthesia mid levels are.

 

[comp1]

NPs are going to be doing different types of work at different levels throughout the country. Their practice rights vary by state law to begin with. I'm sure there are subspecialty NPs doing consults with limited physician oversight at many places. I'm similarly sure some are good at even high level stuff. Quality varies with everything. I don't think that anesthesiology is greatly easier on average than nephrology, even with it being a subspecialty of IM and an overall additional year. CRNAs have been around for 75 years. All that said, the important thing for us is that in mental health there's more than enough well paying business for providers of all types to go around.

 

[Wilf]

This is definitely more system and location dependent than this description. When my partner and I used to work in a rural health care system we had endless jokes about the NP consults that would be placed for the medical subspecialities. The NPs would literally copy/paste notes that were minimally altered/personalized towards the patient. The nephrology ones would have some comments about limiting NSAIDs and contrast for every patient. Cards would have similar comical statements.

I am sure there are plenty of places where subspecialists NPs are doing what you describe, but there are plenty where they are not. We are even seeing places where NPs are doing surgical procedures (of course not all cases, but real cases with real risks) without direct MD supervision in the same way anesthesia mid levels are.

This is ****ing scary. What kind of surgical procedures are they doing? I would be livid if I needed a cardiology or nephrology consult and a clown NP walked in. 😡

 

[Merovinge]

This is ****ing scary. What kind of surgical procedures are they doing? I would be livid if I needed a cardiology or nephrology consult and a clown NP walked in. 😡

I'm slightly paranoid about doxying myself or my partner, and as I have repeatedly shared that she is a subspeciality surgeon, if I mentioned the procedures it would make very apparent what type of surgeon she is. I will say the places that are pushing the boundaries on this are highly financial motivated and it frightens both of us dearly. We turned down living in a geographic location because the practice she interviewed at had midlevels doing this, and even though she would not be required to supervise them, she still did not want anything to do with a group that was doing that at all.

 

[yomike333]

Hi,

Given proliferation of psych NPs, it seems that they are overtaking this field like family medicine through sheer numbers. In fact, there are more psych NP graduates than any other field. It also seems that PP has been deeply affected by these trends. What's your perspective on the future of psychiatry?

Numbers going up does not automatically mean takeover. Demand for mental health care is exploding. There are not enough psychiatrists, especially in rural areas. NPs are filling gaps. The real issue is training depth and supervision, not turf. Psychiatrists will probably shift more toward complex cases, med resistant patients, consult roles. The field is not dying, it is splitting into layers.

 

[Taddy Mason]

Numbers going up does not automatically mean takeover. Demand for mental health care is exploding. There are not enough psychiatrists, especially in rural areas. NPs are filling gaps. The real issue is training depth and supervision, not turf. Psychiatrists will probably shift more toward complex cases, med resistant patients, consult roles. The field is not dying, it is splitting into layers.

So are you a psychiatry resident, anesthesiologist, or pharmacist? You’ve claimed to be all three within an ~3 month period per your post history…

 

[2025DandW]

The job market in my home state, which allows NP/PA/psychologist prescribing, seems a lot less robust than even 3-4 years ago. I rarely hear of openings, except for my former job, which I paid a lot to speed up my retirement in order not to lose my sanity. I did get a mailing that there is a real need in MA and CA, and I have seen a lot of openings in the latter, but there are weird rules concerning residency, very high taxes and potentially a hcol, depending on where you land in CA. I plan to retire in my home state, and I am not hearing or or seeing many openings whether permanent or locums.

 

[Taddy Mason]

The job market in my home state, which allows NP/PA/psychologist prescribing, seems a lot less robust than even 3-4 years ago. I rarely hear of openings, except for my former job, which I paid a lot to speed up my retirement in order not to lose my sanity. I did get a mailing that there is a real need in MA and CA, and I have seen a lot of openings in the latter, but there are weird rules concerning residency, very high taxes and potentially a hcol, depending on where you land in CA. I plan to retire in my homestead state, and I am not hearing or orseeing many openings whether permanent or locums.

I’m currently in the job market in MA and it’s rough - very saturated even outside of Boston.

 

[finalpsychyear]

I love your posts. I know what I said earlier sounds gloomy. But as an immigrant, I think we have a pretty darn good. Heck, overall I think America is pretty darn good if you look at different geographies. I do think healthcare is tougher compared to earlier years. But I don't think in absolute terms, it is hard. There also seems to be a discrepancy between reality and expectations. When I work with younger folk, now i feel old--there seems to be a cultural difference. Like you said, that there is just a great job waiting for them. And by great job, I mean no work. It's always been you need to earn your keep and the nicer jobs are always the more competitive ones. Our pie has more people going after it, so there is a smaller slice. But I'm not the personality that sits and demands a bigger piece of the pie. I make my own bakery. I can still make a decent living doing gen psych but the way the economics shake out, I don't like that volume of that grind in the long term (and it sounds like it will still get tighter). Hence why I do stocks, have a practice that has grown, and other marketable skills I'm pursuing like selling digital products.

I focus on grinding 5 more years at current pace. The talk of np's a decade ago is more prevalent than what the general consensus was saying the same likely is for Ai.

Theres no replacment for busting ur tail, living moderately, and investing till it hurts esp the first 5, 7, or the .01% who do it 10 years out. If ur working hard, growing into spending the 120-150k over that timeline almost guarantees you a work optional life sub 50 or even late 40s.

I would be very upset had i listened to my colleague and coasted working 25-30 hours over the last 10 years losing out on the higher income that invested has been giving like a 15% cagr. You simply can never get that back unless work till 60-65 no thank you.

Reaching FU or FI levels of wealth early will really show you how much you still want to be in medicine or pursue other things. You dont need to worry abt np, ai, etc if ur grinding within reason.

 

[bGMx]

I focus on grinding 5 more years at current pace. The talk of np's a decade ago is more prevalent than what the general consensus was saying the same likely is for Ai.

Theres no replacment for busting ur tail, living moderately, and investing till it hurts esp the first 5, 7, or the .01% who do it 10 years out. If ur working hard, growing into spending the 120-150k over that timeline almost guarantees you a work optional life sub 50 or even late 40s.

I would be very upset had i listened to my colleague and coasted working 25-30 hours over the last 10 years losing out on the higher income that invested has been giving like a 15% cagr. You simply can never get that back unless work till 60-65 no thank you.

Reaching FU or FI levels of wealth early will really show you how much you still want to be in medicine or pursue other things. You dont need to worry abt np, ai, etc if ur grinding within reason.

Appreciate the post... Define "grinding within reason."

 

[finalpsychyear]

Appreciate the post... Define "grinding within reason."

Avoiding nights,wknds, holidays. I took roles over the decade where starting time was 6a and have worked till 7pm just not 5 days in a row. 4-5 wks vaca min if ur pushing hours throughout the year. Small window in ur 30s where u are more eager to do this and way less likely after.

 

[calvinhobbes]

Nope just the opposite. I have so many patients that I see, who are THANKFUL to finally find an MD, because their NP put them on Xanax and Vyvanse and Clonidine and Lamictal for their “bipolar” depression and “fatigue.” Psychiatrists are becoming more sought after because we actually know what the heck we’re doing. Trust me, the worse NPs become — and with over-saturation they are becoming less competent and more desperate — thus the higher the demand becomes for excellent care with MDs).

You can’t “fake” good psychiatric care. Maybe nurse anesthetist NPs can get away with doing “anesthesia,” but an NP cannot replace a psychiatrist who practices real psychiatric medicine with solid training.

 

[Stagg737]

I focus on grinding 5 more years at current pace. The talk of np's a decade ago is more prevalent than what the general consensus was saying the same likely is for Ai.

Theres no replacment for busting ur tail, living moderately, and investing till it hurts esp the first 5, 7, or the .01% who do it 10 years out. If ur working hard, growing into spending the 120-150k over that timeline almost guarantees you a work optional life sub 50 or even late 40s.

I would be very upset had i listened to my colleague and coasted working 25-30 hours over the last 10 years losing out on the higher income that invested has been giving like a 15% cagr. You simply can never get that back unless work till 60-65 no thank you.

Reaching FU or FI levels of wealth early will really show you how much you still want to be in medicine or pursue other things. You dont need to worry abt np, ai, etc if ur grinding within reason.

Avoiding nights,wknds, holidays. I took roles over the decade where starting time was 6a and have worked till 7pm just not 5 days in a row. 4-5 wks vaca min if ur pushing hours throughout the year.

That’s fine, but there’s the flip side too that you miss out on the prime years of your health. Th at can be especially hard if you miss out on the early years of your kids’ lives.

Myself as an example, my kids are in elementary school and most of their activities are on weeknights and start before 7. Working your schedule I wouldn’t be able to coach or participate in those activities with them during the years that are probably the most meaningful for me to be there with them in terms of developing their interests and really creating a strong family bond. We often get less years than we think where our kids are actually excited to spend time with us, and I don’t want to waste that time grinding for 20 years from now when who knows if I’ll even be alive.

Which comes to the second point of our own health. I’m in the second half of my 30’s and 2 years ago I herniated a disc doing basically nothing. It was particularly eye opening because I used to be a high level athlete and never worried about my health outside of sports, but also because my dad has had 5 or 6 back surgeries when I was young and wasn’t really able to do sports with me growing up other than playing horse or tossing a baseball. I really value my physical health and have been working to get back into some competitive activities, but know there’s a good possibility that window may be closing on me fast. Grinding like you are could waste the last few years I have to really get back to competing at the level I want. I also know docs who worked hard and then had something major happen (accident, stroke, cancer, etc) who never got the opportunity to enjoy the fruits of their early labor the way they wanted.

So while I do think there is definitely something to be said about crushing it for 3-7 years and then scaling back a ton, imo it’s not advisable for everyone. If someone has young kids and a family, it’s much less likely to be worth the sacrifice than if you’re single or a DINK whose spouse also wants to hustle for 5 years then cut back. There’s definitely pros and cons, and they should be weighed. Regardless, any psychiatrist willing to work “Full time” (30 hours a week) should be able to make solid headway saving for retirement whether they want to grind like you or prioritize lifestyle like me (I still put $50-60k toward retirement each year, made ~$270k last year).

 

[Stagg737]

How do you all feel about AuDHD? Popping up all over my feeds.

View attachment 414952

Forgot to respond to this. It’s dumb and I hate that Venn diagram. We all know ADHD and ASD have high co-morbidity rates and I see plenty of patients who have both. However I've seen more people saying they’re “AuDHD” because they identify with that light blue section even though they don’t meet criteria for either condition otherwise.

I also hate it because it just reinforces the relatively new trend of people trying to make their diagnoses a major part of their identity and using this as an external locus of blame for their bad decision making or behaviors. I feel the same way about the whole “neurospicy” movement as well. If people want to use those terms to simplify the conversation then that’s fine by me. But when they start using as a means to convey their identity I start having deeper conversations about why they feel the need to do so.

 

[calvnandhobbs68]

That’s fine, but there’s the flip side too that you miss out on the prime years of your health. Th at can be especially hard if you miss out on the early years of your kids’ lives.

Yeah there is nothing that would make me work weekends again at this point unless I literally had no other option for work lol.

Same thing for me with the kids too, that's actually the huge benefit of private practice for me. I get to drop my kids off and pick my kids up from school at least once a week, play with them every weekend, go to my kids soccer games and practice, dance recitals, go to their school for birthdays to have lunch with them and read for their class, not to mention be home before dinner literally every night of the week....I don't care if you paid me 1000 bucks an hour, you'll literally never get that time back again.

In 10 years nobody's going to be asking "can you come play with me?"....they're probably barely gonna want to talk to me so better get it while the gettins good 😆. I think being in child/adolescent too you see how drastically kids change even over a 5 year span from 8-13 or 9-14 and you're like I need to get the time in while I can....

 

[finalpsychyear]

That’s fine, but there’s the flip side too that you miss out on the prime years of your health. Th at can be especially hard if you miss out on the early years of your kids’ lives.

Myself as an example, my kids are in elementary school and most of their activities are on weeknights and start before 7. Working your schedule I wouldn’t be able to coach or participate in those activities with them during the years that are probably the most meaningful for me to be there with them in terms of developing their interests and really creating a strong family bond. We often get less years than we think where our kids are actually excited to spend time with us, and I don’t want to waste that time grinding for 20 years from now when who knows if I’ll even be alive.

Which comes to the second point of our own health. I’m in the second half of my 30’s and 2 years ago I herniated a disc doing basically nothing. It was particularly eye opening because I used to be a high level athlete and never worried about my health outside of sports, but also because my dad has had 5 or 6 back surgeries when I was young and wasn’t really able to do sports with me growing up other than playing horse or tossing a baseball. I really value my physical health and have been working to get back into some competitive activities, but know there’s a good possibility that window may be closing on me fast. Grinding like you are could waste the last few years I have to really get back to competing at the level I want. I also know docs who worked hard and then had something major happen (accident, stroke, cancer, etc) who never got the opportunity to enjoy the fruits of their early labor the way they wanted.

So while I do think there is definitely something to be said about crushing it for 3-7 years and then scaling back a ton, imo it’s not advisable for everyone. If someone has young kids and a family, it’s much less likely to be worth the sacrifice than if you’re single or a DINK whose spouse also wants to hustle for 5 years then cut back. There’s definitely pros and cons, and they should be weighed. Regardless, any psychiatrist willing to work “Full time” (30 hours a week) should be able to make solid headway saving for retirement whether they want to grind like you or prioritize lifestyle like me (I still put $50-60k toward retirement each year, made ~$270k last year).

I got married at 36 and am having kids soonish so this was always my plan as i agree this wont really work for younger parents. The flip side is ive built alot of credit with the places i work so i am 95% remote now.

Depends what u want. Rads, anesthesia are all working closer to 50 hrs a week when u consider call, wknds, holiday coverage to make 500k+. They would love to be able to do 8-6 no night, wknds, holidays and be in that ball park.

They say medicine isnt a sprint which i sorta agree. Thing is im a math guy. Working hardest when youngest and investing everything and capturing the 15% cagr/yr the past decade with no wknds, nights, call, holidays was worth it for me.

Its the sole reason that i could work 30 hrs now and if the markets go well for 5 more years have a sub 50 retirement and spend 300k/yr. Marrying later and kids later helped. Intermittent fasting with some 48-72 hr water or bone broth are keys to longevity and free to do.

 

[DareGreatly]

I got married at 36 and am having kids soonish so this was always my plan as i agree this wont really work for younger parents. The flip side is ive built alot of credit with the places i work so i am 95% remote now.

Depends what u want. Rads, anesthesia are all working closer to 50 hrs a week when u consider call, wknds, holiday coverage to make 500k+. They would love to be able to do 8-6 no night, wknds, holidays and be in that ball park.

They say medicine isnt a sprint which i sorta agree. Thing is im a math guy. Working hardest when youngest and investing everything and capturing the 15% cagr/yr the past decade with no wknds, nights, call, holidays was worth it for me.

Its the sole reason that i could work 30 hrs now and if the markets go well for 5 more years have a sub 50 retirement and spend 300k/yr. Marrying later and kids later helped. Intermittent fasting with some 48-72 hr water or bone broth are keys to longevity and free to do.

I think the balance of how much to work is interesting and an important concept to analyze. As time goes on I tend to side with Stagg's perspective. That said, it's a personal decision that is based off priorities that are going to vary between people. On the surface, FIRE is an attractive goal for a lot of people, but the problem is that you project your current body into the future. What you're able to do at 50 vs 30 is very different. Your risks of various health problems and death continue to increase along the way as well. With prioritizing working more and/or foregoing spending on various experiences, you give up opportunities for some experiences that you may not be able to have later. Additionally, it's riskier to have kids the longer you wait from a health perspective, if you're even able to have them at all. I'm sure we all have anecdotes of folks we know having trouble with conception in their mid to late 30's. Psychiatry is relatively unique because generally we can practice any amount we want and for a long time while still maintaining high hourly compensation. So, FIRE is a bit less attractive than other careers where you have to navigate career risks as you get older - like those requiring climbing a corporate ladder (risks of getting laid off with no job replacement in later career) or blue collar (risks of being unable to work due to physical injury/disability).

 

[Merovinge]

I think the balance of how much to work is interesting and an important concept to analyze. As time goes on I tend to side with Stagg's perspective. That said, it's a personal decision that is based off priorities that are going to vary between people. On the surface, FIRE is an attractive goal for a lot of people, but the problem is that you project your current body into the future. What you're able to do at 50 vs 30 is very different. Your risks of various health problems and death continue to increase along the way as well. With prioritizing working more and/or foregoing spending on various experiences, you give up opportunities for some experiences that you may not be able to have later. Additionally, it's riskier to have kids the longer you wait from a health perspective, if you're even able to have them at all. I'm sure we all have anecdotes of folks we know having trouble with conception in their mid to late 30's. Psychiatry is relatively unique because generally we can practice any amount we want and for a long time while still maintaining high hourly compensation. So, FIRE is a bit less attractive than other careers where you have to navigate career risks as you get older - like those requiring climbing a corporate ladder (risks of getting laid off with no job replacement in later career) or blue collar (risks of being unable to work due to physical injury/disability).

I'm not sure if you read it or not, but this is probably the main theme of the book Die With Zero. Life has seasons of things you can do, and while you can possibly stretch those seasons, mother nature/time remains undefeated. As with everything, there is a balance between doing what your current self wants while also taking good care of your future self.

 

[randomdoc1]

I'm FIRE (except for the part where I'm opting to work for internal purposes...too boring without it). I don't regret it. Not. One. Bit. Do not feel like I missed out on anything. Also helps to teach your kids. I started gathering interest at 15 yo. I'm teaching my kiddos.

 

[finalpsychyear]

I'm FIRE (except for the part where I'm opting to work for internal purposes...too boring without it). I don't regret it. Not. One. Bit. Do not feel like I missed out on anything. Also helps to teach your kids. I started gathering interest at 15 yo. I'm teaching my kiddos.

My defintion of FIRE keeps changing. im likely close to having my basic life expenses covered but i presume a young sub 50 retirement will be more expensive with a few international trips a year. For me in my mind thats when i truly reach it but its a bit hypothetical. However, my just working a few more years and hoping no major crashes occur that might get me close if the market keeps up. Maybe thats more like coast fire. Not sure if people use 3 or 4 % swr to make those calculations these days.

 

[Sushirolls]

I'm somewhat trying to approach retirement from a different angle. Not going to get bogged down by having X amount in the accounts.

Instead I'm looking at the cost of living budget. Things like food, gas, heat, water, electric, entertainment, etc.
Trying to reduce those as much as possible.
Outdoor hobbies, hunting, camping, fishing, nature walks, low cost.
Fuel? Wood gasifier; and now the prep time of getting wood, chunking, and drying is already an enjoyed 'hobby' can run a vehicle for no cash fuel costs. Older simple vehicle I can do repairs myself.
Live on farm and grow everything I want, and have a sizeable green house to grow the items not meant for my USDA Zone. Drastically reduce food bill.
Designed house in way to thrive on wood heat - free.
Well water - free.
Off grid electric - free
Even usables... work gloves? Going to make my own from deer hides I've harvested.

Just looking at the spread sheet of usual retirement costs and seeing how I can prepare things now to reduce or eliminate future expenses.
I've traveled, so not much desire to globe hop in later years.

In summary, one way to make your retirement dollar stretch, is no have the need to spend it in the first place.

 

[finalpsychyear]

I'm somewhat trying to approach retirement from a different angle. Not going to get bogged down by having X amount in the accounts.

Instead I'm looking at the cost of living budget. Things like food, gas, heat, water, electric, entertainment, etc.
Trying to reduce those as much as possible.
Outdoor hobbies, hunting, camping, fishing, nature walks, low cost.
Fuel? Wood gasifier; and now the prep time of getting wood, chunking, and drying is already an enjoyed 'hobby' can run a vehicle for no cash fuel costs. Older simple vehicle I can do repairs myself.
Live on farm and grow everything I want, and have a sizeable green house to grow the items not meant for my USDA Zone. Drastically reduce food bill.
Designed house in way to thrive on wood heat - free.
Well water - free.
Off grid electric - free
Even usables... work gloves? Going to make my own from deer hides I've harvested.

Just looking at the spread sheet of usual retirement costs and seeing how I can prepare things now to reduce or eliminate future expenses.
I've traveled, so not much desire to globe hop in later years.

In summary, one way to make your retirement dollar stretch, is no have the need to spend it in the first place.

Impressed that you have the skills to do this. 99% of us likely can't do this long term.

Whenever i get around to glamping or doing some wknd trip to a Inn at a farm I'm sure its a great place.

The 3-4% rule probably is an easier concept for most people and even safer if they use the budget during their more expensive years to have some padding.
Im in the midwest and most of my friends are not too fancy and basically are spending 150-180k in their raising kids, pseudo nanny/daycare phase. They drive hondas/toyotas or similar.

 

[calvnandhobbs68]

I'm somewhat trying to approach retirement from a different angle. Not going to get bogged down by having X amount in the accounts.

Instead I'm looking at the cost of living budget. Things like food, gas, heat, water, electric, entertainment, etc.
Trying to reduce those as much as possible.
Outdoor hobbies, hunting, camping, fishing, nature walks, low cost.
Fuel? Wood gasifier; and now the prep time of getting wood, chunking, and drying is already an enjoyed 'hobby' can run a vehicle for no cash fuel costs. Older simple vehicle I can do repairs myself.
Live on farm and grow everything I want, and have a sizeable green house to grow the items not meant for my USDA Zone. Drastically reduce food bill.
Designed house in way to thrive on wood heat - free.
Well water - free.
Off grid electric - free
Even usables... work gloves? Going to make my own from deer hides I've harvested.

Just looking at the spread sheet of usual retirement costs and seeing how I can prepare things now to reduce or eliminate future expenses.
I've traveled, so not much desire to globe hop in later years.

In summary, one way to make your retirement dollar stretch, is no have the need to spend it in the first place.

Most of us can cut down on cost of living without living like preppers in the woods 🤣

Some of this sounds like prepper fantasy stuff. Have you even looked into the practicality of a wood gasifier? There's a reason the vast majority of rural areas use propane....it's actually not more cost effective.

Other stuff, if you really like doing it as a hobby is fine but the time/effort isn't actually any more cost effective....it's like woodworking, it's a great and beautiful hobby but it's not terribly cost effective unless you're really good and efficient.
16 dollar deerskin leather work gloves I can get from harbor freight aren't gonna be the thing that let me FIRE or not lol.