Private practice for the high functioning cash paying patient

I've said more than enough on this in previous discussions, but just don't be so sure that those "highly functional...depression, anxiety, eating disorders" patients are a bunch of "highly functional" alcoholics and narcotics addicts, who are just as likely to get better (or not) as the unwashed masses you are attempting to avoid.

psych7711 said:

I'm sure many people will be annoyed with this post I will say that upfront.

When I complete my psychiatry residency, I have no desire to care for the chronically mentally ill....I would prefer not even to deal with patients with psychotic disorders for one or substance abusers who never improve.

What I want is a practice where I have a sliding scale payment plan and do not accept insurance at all.

I want to have patients who have mood and anxiety disorders mainly college population and women. I would also be interested in working at the student counseling center.

Also, I'm not really interested in being on call after hours or weekends and therefore want to screen callers well before I even accept them as a patient.

In private practice, do you always need a psychiatrist covering you 24/7 when on vacation, weekends, etc or can there just be a voicemail telling patients to go to the ER for acute issues? Legally, is this acceptable?

I want to practice about 80% psychotherapy and 20% medication management.

Basically, I do not want work to be my life and I want to care for patients that are highly functional with depression, anxiety, eating disorders. I'm interested in caring for patients who actually contribute to our society.

I've heard of a couple of people who have started practices such as this, but I just need reassurance that this is possible and I'm not wasting my time with psychiatry residency. Am I in the wrong profession? Should I be getting a PhD in psychology or Psy.D or counseling degree instead? I've gone this far so should probably keep going, but I really hate the hospital and many other aspects this job.

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Everything you've mentioned is possible, just not necessarily good care. You (or your coverage) shoudl be available to your patients 24/7 - if you screen as stringently as you hope to, you should be able to limit these call to "real" emergencies. It's not that difficult to arrange a network of colleagues who'll provide coverage if you're away. There can be a sticking point if you accept an insurance in one venue (college health center) you have to accept it in all venues (i.e., if your private practice patient is insured by the same company you accept at the college, you can't insist on a fee for service payment) - but this varies from state to state. There's also the matter of geography - people who are willing to private pay for psychotherapy tend to live in the places with the most psychiatrists.

Just be aware that co-morbidity is out there, and what may look like a simple case can have many more layers. For example, I have yet to see an E.D. case that is only an E.D.....there is usually MDD, maybe an anxiety Dx, maybe some PTSD, substance abuse, etc. Best of luck with your plan, just be aware that most things aren't that easy.

psych7711 said:

I'm interested in caring for patients who actually contribute to our society.

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I am curious about this comment.

I am sure it is doable, but the question becomes where are you going to get the therapy skills needed to be successful in this type of practice? I would speculate that high functioning self payers who are looking for solid psychotherapy are more likely believe that master's level therapists, Pys.D.s, etc. are going to have the better therapy training on average. There is word of mouth too--both in the client community and among practitioners. If you aren't offering effective therapy to your clients, it might be really tough to keep your schedule full as time progresses.

erg923 said:

I am curious about this comment.

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I almost commented on that.....but I figured I'd let it slide.

Originally Posted by psych7711
I'm interested in caring for patients who actually contribute to our society

Theres nothing wrong with this comment. There are alot of substance abusers who have no desire to get better and abuse the system...do they contribute to society?

Red Beard said:

I am sure it is doable, but the question becomes where are you going to get the therapy skills needed to be successful in this type of practice? I would speculate that high functioning self payers who are looking for solid psychotherapy are more likely believe that master's level therapists, Pys.D.s, etc. are going to have the better therapy training on average. There is word of mouth too--both in the client community and among practitioners. If you aren't offering effective therapy to your clients, it might be really tough to keep your schedule full as time progresses.

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That's not necessarily true. First, one would likely do a lot better training at a residency that is connected to a psychoanalytic institute. Then, they should complete the full training in psychoanalysis. That typically takes years to complete. A lot of those with the ability to pay for those services may be more likely to be impressed with someone with an MD or PhD with multiple years of training then master level therapists. (Note, I'm not saying they're anymore or less qualified, just commenting on what they're "more likely" to "believe".)

kumar28 said:

Originally Posted by psych7711
I'm interested in caring for patients who actually contribute to our society

Theres nothing wrong with this comment. There are alot of substance abusers who have no desire to get better and abuse the system...do they contribute to society?

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There are a lot of hypertensive diabetics who have no desire to get better and who abuse the system. How can you possibly exclude an entire diagnostic group based on the actions of a minority? The majority of the substance dependent WANT to get better, DO contribute to society, and CAN be treated.

Sorry--I WAS going to sit this thread out and let psych7711 find out by him/herself over the next few years--but I am NOT going to sit by for this kind of crap.

Chimed said:

That's not necessarily true. First, one would likely do a lot better training at a residency that is connected to a psychoanalytic institute. Then, they should complete the full training in psychoanalysis. That typically takes years to complete. A lot of those with the ability to pay for those services may be more likely to be impressed with someone with an MD or PhD with multiple years of training then master level therapists. (Note, I'm not saying they're anymore or less qualified, just commenting on what they're "more likely" to "believe".)

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Good point.

Great. So now a human's value is defined by how much he "contributes to society." On a medical forum!!!

psych7711 said:

I'm interested in caring for patients who actually contribute to our society.

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Make sure and make this extremely clear to your interviewers, since they are interested in training psychiatrists who actually contribute to our society.

plainfacts said:

Great. So now a human's value is defined by how much he "contributes to society." On a medical forum!!!

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Well we wouldn't want to offend any of our co-workers by suggesting that a human might have intrinsic worth, based possibly on a spiritual relationship with the Deity...

OldPsychDoc said:

Well we wouldn't want to offend any of our co-workers by suggesting that a human might have intrinsic worth, based possibly on a spiritual relationship with the Deity...

Click to expand...

It is possible to do as you mentioned and I know several. They are some of the most well off psychiatrists around.

I think I can kind of understand your 'contribute to society' thing, and at some level I feel the same way. I am interested myself in working with highly motivated people who have the insight and desire to leave a psych dx behind them. At the same time, I recognize that just because someone has fallen through the cracks for years doesn't mean you can't be the one who helps catalyze their change.

On inpatient wards, it was not uncommon for patients with longstanding psych dxs to say 'wow! she actually talked to me! I think I finally understand what's going on!' These people had been in and out of treatment for years before someone actually tried formal psychotherapy on them, in many cases.

If a patient has never been told that they have some power over their lives, it's hard to hold it against them.

kumar28 said:

Originally Posted by psych7711
I'm interested in caring for patients who actually contribute to our society

Theres nothing wrong with this comment. There are alot of substance abusers who have no desire to get better and abuse the system...do they contribute to society?

Click to expand...

Maybe not to YOUR standards, but that is not your judgment to make is it. At least not in a professional role. I am further curious to understand the view of.... if someone is abusing substances, this somehow makes them incapable of any positive contributions in other aspects of their lives? This is poor and flawed logic, no? What if they contribute greatly to the being a caretaker or influence another human being for the better? Does this count? Or do they have to "contribute" in a more mainstream sense, like working a full time job and paying their taxes every April 15th? Were those Enron executives contributing positively to our society? They looked like they were "all American" on the surface. They went to work everyday, had fancy job titles, and ran big companies all with a wife and 1.5 kids. What category to they go into? Obviously, these are rhetorical questions to reinforce the idea that we can't conduct a clinical practice like this because it's a highly subjective value judgment that has no real answer. And, to express the notion that this question has no place in clinical practice because it injects a value judgment upon the client that is contradictory and contraindicated in the therapeutic relationship. I don't particularly enjoy the complex dynamics and issues involved with the substance abusing population, but I do not deem them less deserving, or of less worth because they are otherwise not a "mainstream" member of society. Not wanting to work with that pop is fine, but the reason the OP gave suggests that they would possibly (note I say possibly) judge and assign priority and worth to his/her clients based on how much he/she feels they are "contributing" or functioning. I think most of us could say they would not want their therapist doing this, and would much rather be treated based on our need, NOT the therapist's judgments of our contribution to society, right?

Lastly, Ive met some pretty upper crust rich folk who can pay cash for services, but they are living off trust funds and "running" daddy's company one day per week and playing golf the rest. Is this person "contributing" more to society than say, a depressed alcoholic garbage man with 3 kids who recently got laid off? So, is it really about "contributing", or could it be more about the money they can have for the luxury of therapy services? To me, that is what comment was really getting at. Its about the availability of money in his/her clientèle. I just wish the OP would clarify which of these 2 themes the comment was trying to convey.

psych7711 said:

I want to have patients who have mood and anxiety disorders mainly college population and women.

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If you're male: I'd pretty much recommend any college-age female I know to specifically avoid any psychiatrist specifically searching mainly for a college-age women clientelle. It's kind of skeevy.

If you're female: I'd imagine that if you're a college-age(ish) female now, by the time you graduate medical school and residency, you may find that working purely with people of your gender and age group would be pretty monotonous.

I'm curious to know how you arrived at your conclusions about the type and sort of patients you want to treat?

Based on your description I actually wonder if you should really be going in to medicine given that there seems to be a certain lack of empapthy and regard for intrinsic value of humanity which in my experience is a large part of medicine, certainly a large part of psychiatry.

Given that you're a juniour member I wonder (seriously) if you might want to rethink your career choice, you could probably meet a lot of the needs you described by studying law and working in the corporate law area- with no need to worry about being called out after hours etc... just a thought.

masterofmonkeys said:

I am interested myself in working with highly motivated people who have the insight and desire to leave a psych dx behind them.

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I think that's a pretty naive view. I would seriously question the degree of insight of anyone who thinks they could just "leave a psych dx behind them." Psych disorders are more similar to diabetes and hypertension than they are to pneumonia...which is to say, becoming and staying healthy is a daily process that requires a lifetime of work, as opposed to a single magic pill. There are no easy fixes.

hippiedoc13 said:

I think that's a pretty naive view. I would seriously question the degree of insight of anyone who thinks they could just "leave a psych dx behind them." Psych disorders are more similar to diabetes and hypertension than they are to pneumonia...which is to say, becoming and staying healthy is a daily process that requires a lifetime of work, as opposed to a single magic pill. There are no easy fixes.

Click to expand...

more like over-analysis of a simple statement. Perhaps a little too simply stated. And I'd argue that in many cases mood/eating/anxiety disorders are more like weight loss than hypertension/diabetes. You can be 'cured' but you have to work to maintain it.

Just had an anorexic (ex-anorexic, I guess), avoidant trait girl I'd worked with back in the day call me yesterday cuz she hadn't eaten in two days due to stuff that had been going on at work and in relationships. She conquered anorexia 'proper' five years ago. And is one of the most insightful and motivated people I have ever had the pleasure of working with. She's smart enough to know when she's about to decompensate and smart enough to try to find her center, and failing that, get help. She's now a charming young lady who is no longer caged by her psychiatric past. I'm not stupid.

What I mean by 'leave a psych dx behind them' is getting to the point where they are able to push past BEING DEFINED by their disorder.

Red Beard said:

I am sure it is doable, but the question becomes where are you going to get the therapy skills needed to be successful in this type of practice? I would speculate that high functioning self payers who are looking for solid psychotherapy are more likely believe that master's level therapists, Pys.D.s, etc. are going to have the better therapy training on average. There is word of mouth too--both in the client community and among practitioners. If you aren't offering effective therapy to your clients, it might be really tough to keep your schedule full as time progresses.

Click to expand...

i think you are heavily overestimate people's opinions on this matter. There are probably a disturbing number of med students who probably get psychiatrist/psychologist mixed up, let alone the general public. If they think you are an MD and can hand out medications, I'm pretty sure most people will assume youre the most experienced.

erg923 said:

Maybe not to YOUR standards, but that is not your judgment to make is it. At least not in a professional role. I am further curious to understand the view of.... if someone is abusing substances, this somehow makes them incapable of any positive contributions in other aspects of their lives? This is poor and flawed logic, no? What if they contribute greatly to the being a caretaker or influence another human being for the better? Does this count? Or do they have to "contribute" in a more mainstream sense, like working a full time job and paying their taxes every April 15th? Were those Enron executives contributing positively to our society? What category to they go into to? Obviously, these are rhetorical questions to reinforce the idea that we can't conduct a clinical practice like this, because it's a highly subjective value judgment that has no real answer. And, to express the notion that this question has no place in clinical practice because it injects a value judgment upon the client that is contradictory and contraindicated in the therapeutic relationship. I don't particularly enjoy the complex dynamics and issues involved with the substance abusing population, but I do not deem them less deserving, or of less worth because they are otherwise not a "mainstream" member of society. Not wanting to work with that pop is fine, but the reason the OP gave suggests that they would possibly (note I say possibly) judge and assign priority and worth to his/her clients based on how much he/she feels they are "contributing" or functioning. I think most of us could say they would not want their therapist doing this, and would much rather be treated based on our need, NOT the therapist's judgments of our contribution to society, right?

Lastly, Ive met some pretty upper crust rich folk who can pay cash for services, but they are living off trust funds and "running" daddy's company one day per week and playing golf the rest. Is this person "contributing" more to society than say, a depressed alcoholic garbage man with 3 kids who recently got laid off? So, is it really about "contributing", or could it be more about the money they can have for the luxury of therapy services? To me, that is what comment was really getting at. Its about the availability of money in his/her clientèle. I just wish the OP would clarify which of these 2 themes the comment was trying to convey.

Click to expand...

Nice point...the point in bold was a very solid reasoning that i will use on my own..any time another practitioner starts complaining about all the low life's clogging up their lives. Assigning a value number to a human being is a slippery slope at best.

psych7711 said:

I'm sure many people will be annoyed with this post I will say that upfront.

When I complete my psychiatry residency, I have no desire to care for the chronically mentally ill....I would prefer not even to deal with patients with psychotic disorders for one or substance abusers who never improve.

What I want is a practice where I have a sliding scale payment plan and do not accept insurance at all.

I want to have patients who have mood and anxiety disorders mainly college population and women. I would also be interested in working at the student counseling center.

Also, I'm not really interested in being on call after hours or weekends and therefore want to screen callers well before I even accept them as a patient.

In private practice, do you always need a psychiatrist covering you 24/7 when on vacation, weekends, etc or can there just be a voicemail telling patients to go to the ER for acute issues? Legally, is this acceptable?

I want to practice about 80% psychotherapy and 20% medication management.

Basically, I do not want work to be my life and I want to care for patients that are highly functional with depression, anxiety, eating disorders. I'm interested in caring for patients who actually contribute to our society.

I've heard of a couple of people who have started practices such as this, but I just need reassurance that this is possible and I'm not wasting my time with psychiatry residency. Am I in the wrong profession? Should I be getting a PhD in psychology or Psy.D or counseling degree instead? I've gone this far so should probably keep going, but I really hate the hospital and many other aspects this job.

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I think that you should mention what you're looking for in a patient to your patients before you take them on. They should know what they're getting as a physician; it's only fair.

This is one of the best posts I've seen in a while.

From a practicality standpoint, I wonder what would bring one to this point - if you don't like caring for the chronically mentally ill why ever even consider psychiatry? It's like a surgeon being afraid of blood.

I'm not even going to touch the addiction stuff - except for saying that assisting someone in their getting sober might be as good a thing as a medical professional can do.

During residency you're def going to have to take care of the chronically mentally ill. Do you want to do that for four years? Consider MSW or path.

I think it's easy for us to sit here with our 'holier than thou' attitudes, and speak of the audacity that the OP has in stating that they don't want to treat addiction or chronically mentally ill patients.

However, the elephant in the room is that there are many, many psychiatrists that screen patients over the phone for acuity and whatnot. There are myriad reasons for this: high value of personal or family time which they do not want constantly interrupted with phone calls and problems, litigation fear (though the research would show that higher SES patients sue more often, though the perception is often the opposite), or personal experiences whereby the poster is riddled with malingering or revolving door patients and has reached an early burn-out state, or is in difficult, cynical training.

There are many outpatient boutique practitioners that can't or won't deal with 'the other side.' This includes general medicine (not all IMs work in county clinics), subspecialties of surgery (not all plastic surgeons are doing overseas work fixing clefts), etc.

I'll admit that while I'm looking for jobs right now, I am tending to shy away from the tough call places, high acuity/low support situations. I have no desire to do social work ever again, and one can graduate from residency quite jaded. Granted, I'll likely be involved in a mixture of inpatient/outpatient by choice, but to blanket statement the OP with the idea that all doctors must see the patients which we see as most deserving, may not be right also.

It's an offensive post.

OldPsychDoc said:

Well we wouldn't want to offend any of our co-workers by suggesting that a human might have intrinsic worth, based possibly on a spiritual relationship with the Deity...

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BobA said:

It's an offensive post.

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I thought there was only one line that was offensive (the "contributing to society" part - completely indefensible), otherwise I can't really see anything wrong with wanting to see a particular patient population. If someone wrote "Jeez, I just can't stand working the neurotic middle class" or "I really don't think that providing psychotherapy for Cluster B college students with eating disorders is a rewarding use of my training" and espoused a desire to only work the severely mentally ill, they'd probably face a whole lot less criticism and likely a fair number of accolades. I'm not sure why the reverse causes so much consternation. I say to each his own - I like treating the agitated delirious, the withdrawing addict, and the medically-ill psychotic, but I don't mind that others do not. I'm happy that folks actually want to take care of the populations that I'm NOT interested in.

Doc Samson said:

I'm not sure why the reverse causes so much consternation.

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The same reason we condemn plastic surgeons who do nothing but cosmetics, and condemn specialty cardiology hospitals that take well-insured patients away from the hospital with the busy ER down the street.

It skims the easy cash off the top. And if you skim easy cash off the top, people will hate you. Most of us want self-respect AND the cash. When somebody else just wants the cash, they upset our balance. Suddenly our self-respect has to be MORE valuable. And most of us are pushing its limits already with self-delusion.

Can't tell I'm on call, can you?

UPDATE: To be clear, I'm saying we condemn them because we are narcissists. And because I'm spending too much time reading The Last Psychiatrist on call.

I don't begrudge anyone who invest the time/effort/etc to put themselves in a position where they can cherry pick. I'll be honest and share that because I don't plan on having a large PP (~1 day a week).....it makes more sense to do cash pay and cherry pick, and I can understand if a psychiatrist wants to have a practice and not be on call at all hours of the night. It may seem unfair to some, but most/all other professionals do this every day.

billypilgrim37 said:

The same reason we condemn plastic surgeons who do nothing but cosmetics, and condemn specialty cardiology hospitals that take well-insured patients away from the hospital with the busy ER down the street.

It skims the easy cash off the top. And if you skim easy cash off the top, people will hate you. Most of us want self-respect AND the cash. When somebody else just wants the cash, they upset our balance. Suddenly our self-respect has to be MORE valuable. And most of us are pushing its limits already with self-delusion.

Can't tell I'm on call, can you?

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But is private practice psychotherapy "skimming easy cash?" More than private practice psychopharm where you're doing 15 minute visits and often continuing a course of treatment? More than a salaried hospital job where you get paid the same amount whether there are patients or not? More than a state hospital where you only have to write a note once a week and basically just make sure the patients don't kill each other (or have sex with each other)? Just because patients have disposable income or good insurance it doesn't mean that a) they don't need treatment, or b) that they're easy to deal with.

I think part of the equation involves recognizing the cost to society to train a psychiatrist, or any other specialist, and then having them turn their backs on those we've trained them to care for. It probably costs the goverment a half million or more (total guestimation) per physician if you consider both residency and state medical school subsidies, and then to have them turn around and get rich doing cosmetic surgery, cosmetic derm, psychotherapy for the worried well....kind of a ****ty deal for the rest of us tax payers!

Doc Samson said:

But is private practice psychotherapy "skimming easy cash?"

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My knowledge of private practice psychotherapy is essentially nil (which is of course what happens when you choose all of your education more than four hours away from the nearest ocean). But my perception of private practice psychotherapy is rich and vibrant!

Given the # of SDN threads that have had subject lines like "How can I make a jillion dollars a year without actually doing any work" which have resulted in anecdotes about cash-only practices of any and all persuasions, I don't think it's hard to trace the origins of these perceptions.

It may not be fair to associate all private practice psychotherapy with massaging the neuroses of rich white people (who, no doubt, are the only type of folks who really contribute to society), but am I alone when I think Woody Allen films have made the two pretty hard to separate? I doubt it.

Red Beard said:

I think part of the equation involves recognizing the cost to society to train a psychiatrist, or any other specialist, and then having them turn their backs on those we've trained them to care for. It probably costs the goverment a half million or more (total guestimation) per physician if you consider both residency and state medical school subsidies, and then to have them turn around and get rich doing cosmetic surgery, cosmetic derm, psychotherapy for the worried well....kind of a ****ty deal for the rest of us tax payers!

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I guess I don't equate psychotherapy with a "cosmetic" procedure. The attitude that psychotherapy is "not real medicine" smacks of a carve-out mentality.

billypilgrim37 said:

My knowledge of private practice psychotherapy is essentially nil (which is of course what happens when you choose all of your education more than four hours away from the nearest ocean). But my perception of private practice psychotherapy is rich and vibrant!

Given the # of SDN threads that have had subject lines like "How can I make a jillion dollars a year without actually doing any work" which have resulted in anecdotes about cash-only practices of any and all persuasions, I don't think it's hard to trace the origins of these perceptions.

It may not be fair to associate all private practice psychotherapy with massaging the neuroses of rich white people (who, no doubt, are the only type of folks who really contribute to society), but am I alone when I think Woody Allen films have made the two pretty hard to separate? I doubt it.

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Rich white people need doctors too. Regardless, psychotherapy is far from "massaging neuroses", and it's not just for rich white people.

My career and training has been as gritty/frontline/in the trenches as I could make it, but I take exception to the dismissal of outpatient psychotherapy as a needless luxury and its practitioners as parasitic. Again - psychotherapy is real medicine.

Doc Samson said:

Rich white people need doctors too. Regardless, psychotherapy is far from "massaging neuroses", and it's not just for rich white people.

My career and training has been as gritty/frontline/in the trenches as I could make it, but I take exception to the dismissal of outpatient psychotherapy as a needless luxury and its practitioners as parasitic. Again - psychotherapy is real medicine.

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I love you. I hope to do plenty of "gritty/frontline/in the trenches" psychiatry, but I also plan on making psychotherapy the focus of my career. Especially if you practice psychodynamic therapy, where you really have to put yourself out there, there doesn't seem to be that much that can be called easy about it. And the pay situation if you take insurance sucks. Hardly skimming off the top if you don't limit yourself to cash payers.

Doc Samson said:

My career and training has been as gritty/frontline/in the trenches as I could make it, but I take exception to the dismissal of outpatient psychotherapy as a needless luxury and its practitioners as parasitic. Again - psychotherapy is real medicine.

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I don't think I'd disagree with that sentiment at all, and I don't think this is a dismissal of psychotherapy at all, but rather a dismissal of a certain attitude that comes across in the OPs words. Absolutely psychotherapy is real medicine. Hell, it should probably billed as what it is, a procedure, since it's decidedly doing something.

Rich white people with real pathology need doctors, absolutely. If you're rich and white and depressed, or bipolar, or just lost a family member and need some therapy to keep from slipping down a terrible slope, or need some MI to help you maintain your sobriety, beautiful! This is not anti-therapy. This is anti-"I want to set up a 'sliding scale' practice which will soon make me half a million a year as I continually am able to weed out needy people because the only people I accept are people who will 'contribute to society' by my own ever-increasingly rigid standard." And no, the OP does not say these things, I am saying them for him, because that is exactly the attitude he conveys.

The difference is, rich white people don't NEED real pathology to pay hundred of dollars an hour for psychotherapy. They need someone who is willing to reinforce their egocentricity. And someone who is willing to screen based on a patient's ability to "contribute to society" sounds like just the ticket.

So if we're going to disagree, let's disagree for the right reasons. My problem with the OP's practice model is the way it inevitably makes psychotherapy a commodity rather than a medical procedure. If I am making assumptions that aren't true about how his practice will develop, then my argument probably falls entirely flat. But given the tone to which most of us have reacted very negatively, it's hard not to assume the worst.

What if the OP said this?

"Hey, I believe in the American dream, and I really want to work with young people whose goals are being destroyed by psychopathology. I've always been drawn to the complexity and challenge of psychotherapy, which is a very different sort of complexity and challenge than the sort of work that goes into treating chronic, 'severe' mental illness, and I imagine my practice being weighted heavily towards talk therapy, given its efficacy demonstrated across any number of clinical trials. I think psychotherapy should be open to all people regardless of their ability to pay, and I've seen sliding scale cash practice models which have made therapy available to people who otherwise would be shut out from it. Also, I'm particularly fascinated with the means by which society has created unique pressures on young women and the implications of those pressures when someone has a mental illness, and I would very much like to work with that population as well."

But he didn't say any of these things. And that's what we're responding to so vehemently.

There are many anti-psychotherapy threads on here. I don't think this is one of them.

OP, did you consider that the clientele you are shooting for are least likely to put up with a voicemail telling them to bugger off to ER with urgent concerns after hours?

Just wondering.

kumar28 said:

Originally Posted by psych7711
I'm interested in caring for patients who actually contribute to our society

Theres nothing wrong with this comment. There are alot of substance abusers who have no desire to get better and abuse the system...do they contribute to society?

Click to expand...

I have always thought there are a lot of substance abusers who have not been able to get well enough to desire getting better. I do not necessarily think they abuse the system; rather, the system is not working very well with them.

The OP said he wanted a sliding scale, fee-for-service only private practice and some salaried student health center work. This is not a way to to make a lot of money. It is, however, a way to exercise some control over the types of pathology that you treat AND to avoid dealing with the endless paperwork and dismissive attitude of insurance companies. I guess I'm not seeing the purely financial motive here.

billypilgrim37 said:

real pathology

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What's the definition here? DSM-IV diagnosis? Suffering is suffering, no matter how "superficial" someone else might think it is.

Doc Samson said:

What's the definition here? DSM-IV diagnosis? Suffering is suffering, no matter how "superficial" someone else might think it is.

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Not all suffering falls within the realm of psychiatry or medicine.

billypilgrim37 said:

Not all suffering falls within the realm of psychiatry or medicine.

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In the hospital setting I agree, but existential suffering is a prime target for long-term outpatient psychotherapy.

I find it interesting that we have not had any follow-up postings from the OP, despite the spirited discussion over a week's time. Looking over his/her posting history, I note that there was a similiar hand grenade lobbed into the forum by this poster in February, complete with citations of a clearly anti-psychiatric site. I guess you might say that I am questioning their intentions at this point.

From my perspective, I am not nearly so offended by the OP's stated desire to target one's practice or to emphasize psychotherapy as I am by the intention to limit their attentions to those determined arbitrarily to be making a "contribution to society", and by the implication that the SPMI and substance dependent population is excluded from that group.

I'm done. Thanks for listening.

Red Beard said:

I think part of the equation involves recognizing the cost to society to train a psychiatrist, or any other specialist, and then having them turn their backs on those we've trained them to care for. It probably costs the goverment a half million or more (total guestimation) per physician if you consider both residency and state medical school subsidies, and then to have them turn around and get rich doing cosmetic surgery, cosmetic derm, psychotherapy for the worried well....kind of a ****ty deal for the rest of us tax payers!

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Well, one could easily argue the opposite point, and say that resident physicans provide billions of dollars of medical treatment yearly for paltry sums of money. That includes the derm resident working in the county hospital clinic where there may be few or no actual paying patients.

OldPsychDoc said:

I find it interesting that we have not had any follow-up postings from the OP, despite the spirited discussion over a week's time. Looking over his/her posting history, I note that there was a similiar hand grenade lobbed into the forum by this poster in February, complete with citations of a clearly anti-psychiatric site. I guess you might say that I am questioning their intentions at this point.

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I noticed the same. Well, at least we can have a lively discussion even if the OP has bowed out.

From my perspective, I am not nearly so offended by the OP's stated desire to target one's practice or to emphasize psychotherapy as I am by the intention to limit their attentions to those determined arbitrarily to be making a "contribution to society", and by the implication that the SPMI and substance dependent population is excluded from that group.

I'm done. Thanks for listening.

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Just a marginally related comment which compliments what OPD is saying better than I...

I'm not the biggest fan in the world of the addiction population. They've incredibly frustrated me at times during my residency. However, I must also say that I've moonlit for a long time now at an outpatient addictions center. It's a very different animal, and to see these patients and help them along their journey is quite rewarding. Sure there are bumps in the road, but you can see, hear, and feel the disappointment in them when they stumble, which happens often. If one were to take it one step further, I would say that those who get the beligerent, entitled, antisocial addict from the ER setting all the way through to interested outpatient recovery is quite a job, and should be commended.

It is rarely as black and white as your examples (child molesters)....most people are probably somewhere in between. It'd be much easier if things were more clear cut, but that well groomed, highly functioning, cash pay client....could also be a child molesters, since CM's don't just hang out in old vans and dingy apartments.

As for the business stuff.....it can be hard sometimes for professionals to see the "business" in their services. I am business minded and I have a niche area in mind, but I think it will be a work in progress.

psych7711 said:

Thanks to everyone for contributing to this post...

First of all, I will apologize for my comment regarding caring only for those who "contribute to our society."

What I was trying to convey is this...So, you are on call in a city hospital ER and homeless, drug seeking, manipulative patients continue to come through the door. They don't have jobs, have often served time in jail, many have committed crimes such as molesting children or abusing others and continue to cause problems out on the streets....Do they honestly contribute to our society.

Does the child molester really contribute to our society. I can't take care of those who sexually or physically abuse others, I just can't deal with. In my opinion, if someone has hurt a child then they have taken away from society and they would NEVER have an appointment with me.

I understand how all of you seem to act like you enjoy caring for everyone, even people I described above but honestly what do you value about the other parts of your life? Are you trying to reach out to receive internal gratification that you don't have in your personal lives? Just a thought because you all seemed to be so judgmental.

At the end of the day, this is a job and a practice is a business. Granted, it is a business of caring for patients which complicates things, but it's still a job. Any other profession would call the shots as I'm suggesting in a heartbeat.

Any patient I take on, I assure all of you I would do a great job, when I'm in the office and if the patient pays me. I'm not going to work for free though. And I'm not taking on patients that don't interest me, how would that be helpful to anyone?

Any other profession is allowed to do this....Lawyers carve out their specialties....corporate law, real estate, banking, etc...so why can't the medical profession.

I hate to break it to all of you, but the dermatologist who does mainly cosmetic work like botox, restylane, etc and asks for cash from wealthy parents to treat their children's acne....they are smart as hell. That is why the field is so competitive, because you can call the shots.

It doesn't make us evil physicians for being picky....it makes us smart business owners.

At the end of the day, I want to be home with my own family. I want my children to really know who I am. I want to be a good wife. I also would like to be a great physician, and this is why I have to limit my practice. Otherwise, I could not be the person I want to be to those who mean the most to me. Family and personal sanity comes first.

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There is a division in medicine of people who view the work as a profession vs. those that view it as a job. Both can run it as a business (i.e. with a motive for profit), but the former also involves some level of altruism. If there isn't some real altruistic motive to your work then IMHO you're no longer a physician, you are a technician.

And in terms of your child-molesting example, I'd say the question isn't whether or not they HAVE contributed to our society, it's if they CAN do so - any potential they have requires treatment from us. I know I sound naive, but this clinical optimism is a large part of what keeps me coming to work everyday (that and an utterly selfish intellectual curiosity to see what completely novel presentation of mental illness the world is going to hurl at me that day).