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- Thread starter AnesvsPsych
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Clarifying question - what do you like about psychiatry?
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This you OP? Oh yeah it is. Go search for the zillion other threads about this.
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This needs to be said more often on SDN:
Nobody who completes a residency is going to have trouble paying off their loans, not even the lowest paid peds hospitalist. You might not be able to keep up with the average ortho surgeon, but you'll be living in the same neighborhood.
All that being said, to quote White Coat Investor, the variability within a specialty is more than the difference in averages between specialties. I know a couple of folks making ~$200k, working for a legit non-profit (not a hospital system), one making 7 figures, and more than a few making over $500k. All that to repeat, you won't have trouble unless you choose to have trouble, or make a number of bad decisions.
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The average salary in psychiatry is about 280k, whereas it is over 400k in anesthesiology. MGMA (which tends to focus on salaries in the private sector and thus somewhat higher pay) puts anesthesiology at about 470k whereas psychiatry is about 300k. By any metric, there is a substantial difference between pay in anesthesiology and psychiatry. Psychiatry is no longer a lowest paying salary like FM/Peds/ID, but it is on average a lower paying specialty, whereas anesthesiology is still one of the highest paying specialties.
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If you want to devote your professional life to caring for people who struggle with mental illness, then pursue psychiatry; if you don’t want to do that, choose another specialty. Don’t waste the one life you’ve been given on a craft you don’t feel passionate about. Also, most psych patients have been through enough s**t in their lives, and they don’t deserve to have a psychiatrist who just views the field as an opportunity to buy sports cars and summer homes.
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I’m not talking about “completely disregarding practical things.” Salary and lifestyle are obviously parts of the equation when selecting a specialty.
In your prior thread asking for advice on whether to pursue Psych or Gas, you were completely preoccupied with financial and lifestyle factors. When people on that thread asked you to elaborate further on the reasons you’re interested in the specialties, you were defensive and evasive. And now you’re back here to ask about salary. Can you see why some might wonder if you actually have a genuine interest in the day-to-day work that a psychiatrist performs?
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This not direct enough for you?
I feel like it needs to be stated that, while this is true regarding the average, one can waltz into an inpatient gig, do their own billings and generate half a million a year after expenses. And not work more than 30 hours a week. These jobs are a dime a dozen.
You change user names yet keep asking the same question. I'm pretty sure these threads are nothing more than fuel for your fantasy zillow and exotic car searches. I have no doubt you sit around day dreaming about your future earning potential and what type of lifestyle that may bring you. It's transparent, old, and completely played out at this point.
You've exhausted the responses you're going to get on SDN. Why not move along to Reddit?
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As someone who has had multiple psych providers AND had general anesthesia several times for various procedures/surgeries, from what I have observed of your personality on this forum, I hope you choose anesthesia 🙃
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Psych is interesting to almost anyone, one reason psychology is the most popular undergrad and degree. What you describe as your interest sounds more aligned with that type of typical interest than someone who is going to really enjoy the intricacies of the central nervous system and it’s interactions with tye rest of the systems of the body, especially endocrine, and then the dynamic interaction between that internal environment and the external environment and how that leads to behavior and how you effectively intervene through verbal procedures while adding in the complexity of changing up some of that internal world by adding in psychotropic medications. Most of us love this crap. Of course, money is part of the equation, but if you choose psychiatry you might find that you wish you could anesthetize more patients than you can imagine. I love my career choice and there are still days when I wish half my patients were asleep.
I think it could help having some best practices for these threads - not to squash free speech, but to try ensure that money-focused threads relate to specific, non-googleable and not already discussed to death finance related issues. And that when discussing how to make X amount of $ by doing Y, ensuring that there is equal focus on how the proposed approach is a good one for our patients, so that the entire conversation is contextualized and broader than income maximization.
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The only real downside of anesthesia you mentioned were moments of high stress. Adopt a growth mindset and realize that's what residency is for! By the time you have to manage those trainwrecks solo you will be well prepared.
Nothing you mentioned about psychiatry suggests a strong interest aside from lifestyle. As others have mentioned, anesthesia is likely a route to higher income at least on average, and if you are actually more drawn to it I think it's the right choice. Psychiatry is an amazing specialty for some, but if you don't feel a very strong draw and you feel psychiatry residents are not "your people" then it could also end up being pretty stressful in its own way.
Nothing you mentioned about psychiatry suggests a strong interest aside from lifestyle. As others have mentioned, anesthesia is likely a route to higher income at least on average, and if you are actually more drawn to it I think it's the right choice. Psychiatry is an amazing specialty for some, but if you don't feel a very strong draw and you feel psychiatry residents are not "your people" then it could also end up being pretty stressful in its own way.
Had pondered the idea of training in anaesthetics as was always a gun at cannulation and other procedures as an intern. Was also considered to be quite calm and level headed, to the point that one of my supervising surgeons thought I should apply - he also felt psychiatry were full of lazy doctors and I’d be wasted there.
I had done one anaesthetics rotation as a student, and while I enjoyed the intellectual discussions with the anaesthetists as well as being reasonable at intubation, there was one incident that made me think it wasn’t for me. One of them was stressing that it was all about one on one care, and how you really got to know a patient - and in the same breath she forgot the patient’s name when trying to wake him up.
Some had described anaesthesia as 1% excitement, 99% boredom, but after my first impatient psych job where each day was full of crazy interesting stuff I realised that 1% just wasn’t enough. When I moved interstate to start training, I also stayed with an anaesthetist who resented having to work 12+ hour days, and always seemed to complain about the surgeons and drank every night. Earnings hadn’t really been a consideration back then, but knowing what I know now I figure that even though I could earn more, I’d still earn less than the surgeon, so I think that regular comparison would have caused me to resent things more.
In the end, for me what it came down to was autonomy and I didn’t want my ability to work to be reliant on someone else (i.e. the surgeon). As a practical advantage, psychiatry had low barriers to entry, low infrastructure costs and a clinician shortage. If you’re curious about people, i.e. their beliefs and what drives them, psychiatry can be very rewarding. In contrast, I always felt that anaesthesia had more of a focus on monitoring and numbers, as opposed to the subjective experience of the patient.
I had done one anaesthetics rotation as a student, and while I enjoyed the intellectual discussions with the anaesthetists as well as being reasonable at intubation, there was one incident that made me think it wasn’t for me. One of them was stressing that it was all about one on one care, and how you really got to know a patient - and in the same breath she forgot the patient’s name when trying to wake him up.
Some had described anaesthesia as 1% excitement, 99% boredom, but after my first impatient psych job where each day was full of crazy interesting stuff I realised that 1% just wasn’t enough. When I moved interstate to start training, I also stayed with an anaesthetist who resented having to work 12+ hour days, and always seemed to complain about the surgeons and drank every night. Earnings hadn’t really been a consideration back then, but knowing what I know now I figure that even though I could earn more, I’d still earn less than the surgeon, so I think that regular comparison would have caused me to resent things more.
In the end, for me what it came down to was autonomy and I didn’t want my ability to work to be reliant on someone else (i.e. the surgeon). As a practical advantage, psychiatry had low barriers to entry, low infrastructure costs and a clinician shortage. If you’re curious about people, i.e. their beliefs and what drives them, psychiatry can be very rewarding. In contrast, I always felt that anaesthesia had more of a focus on monitoring and numbers, as opposed to the subjective experience of the patient.
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I don’t like talking to them much either unless that are stable in their sobriety. I see my job as keeping them out of my practice and getting them to where they need to be. I’ve gotten pretty good at that and put my energy where it has mist effect. Helping a patient with schizophrenia develop insight into need for treatment which can be exceptionally challenging is something I am enjoying right now and also helping patients with multiple psychiatric placements function independently in community settting with wrap around supports including psychiatric care. In my mind a good mental health clinician should be trying to work there way out of a job and that’s what we‘re doing. Less meds and less therapy and less supports and sometimes even get to zero or just as needed.
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Why?
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If you go into psychiatry for the money you will be miserable. It is quite bad for your personal sanity and wellbeing if you do not genuinely enjoy the patient population and their challenges, something I can tell you after having run into a few people that were just in psych for the money and hating it. Anesthesia can be a clock in and clock out kind of job, with little emotional investment being necessary in the work. Your brain can't go on autopilot as much in psychiatry if you intend to have good patient outcomes, and that's the big issue a lot of "for the money" types don't get. Doctor-patient relationship directly impacts patient outcomes to a substantial degree in our field, and maintaining those relationships can take the kind of emotional bandwidth many are lacking when they don't have an emotional stake in the field.
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If you had been paying attention, you would have noticed that the pay is lower because psychiatrists choose to work a different lifestyle. People talk a lot about better outcomes in psychiatry with a smaller patient panel / fewer outpatient visits per day.
I imagine it's similar for ophthalmologists who spend more time with their outpatients, too. People just don't talk about it quite the same way.
Not as uncommon for internal medicine doctors to round on 40 inpatients as it is for psychiatrists. They're both probably making just as many clinically significant errors. They probably both have just as many outcomes influenced by their rushed interpersonal styles. People just talk about it more in psychiatry.
Not uncommon at all for FP to see 40 outpatients a day. Those doctors generally also have terrible rapport, patient investment in treatment, and responses to treatment.
Why would you do that to yourself though?
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There are and they do. A Prozac/Seroquel/Xanax pill mill is easier to set up than a Z pack/Prednisone/Norco pill mill. Generally less scrutinized, too. I would never be a patient at either. Breaking the law generally is somewhat lucrative up until the law gets enforced.
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They exist and they tend to have horrible reputations with their patients and the community
Half my patients do end up asleep after I round. I have developed quite the skill set getting them pissed off since I do not argue or discuss dc dates as they yell at me. Which only adds fuel to the fire. Oddly I find it very entertaining
40 in OP would be nearly impossible unless you are working 12+ hr days and have a lot of staff and see people for 5 min checks. Inpatient you can cover that many once in a while but to maintain 40 as your patients also damn near impossible because the little things that need follow ups pile up. When covering you dont generally have to do all those small things so that makes in more manageable
There is no way a psychiatrist would want to see 40 patients in outpatient. The best case scenario, you spend 15 minutes for each patient visit + note, it would be equal to 10 hours of work and this is only for follow ups. That does not count in the fact that one in every three patients will bring up something in the session that will take more than 15 minutes to tackle. so add extra 2-3 hours of work there as well. So the best case scenario, you are looking at working 12 plus hours a day minimum and providing ****ty care. I dont know any psychiatrists who is doing it. It is more doable in inpatient psychiatry though.
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I know one psychiatrist who did 30 patients a day and was actually not bad. He was also really experienced and smart. He did not get to that point right away either; it took years of building his skill. He has since decided to slow down.
Having trouble determining what one should expect to bill for inpatients. I feel like outpatient codes have been talked to death around here, but in thinking about taking an inpatient job I'm wondering what I might actually make if I did my own billing.
It's very easy and an interesting discussion - why don't you start another thread as this thread is a mess.
Depends on your area and payor mix. I can tell you in the Midwest city I’m in medicaids pay $43 for a 99232 and $100 for a 99223. Therapy codes 90833 pay 60-80 from Medicaid’s.
Medicare pays $80 and $140 respectively
BCBS is closer to $100 and 180 respectively.
So you area and your payor mix will move these numbers and will change your outcome of what you can make. Also your efficient and ability so see volume of patients will shift things.
Personally I’ve really worked to be efficient and I’m also lucky and have good teams to work with so I can fully just focus on my patients. I also see a very sick population most of my patients will be on at least a fully dosed mood stabilizer and antipsychotic and one lower dosed antipsychotic because of their illness severity. So I can see a high volume without causing a decrease in care nor complaints from patients or families. So because of that I easily sit in the 99th % of income.
Appreciate you spelling that out. So if I'm interpreting this correctly, with a 232 and therapy add on, you're generating 103-123 per pt encounter with Medicaid. With BCBS you're generating 100 + whatever they reimburse add on therapy at? Can you speak to what they (and Medicare) reimburse therapy at?
Also, do inpatient therapy codes have the same time requirements? So 16 minutes minimum..?
So assuming a patient panel of 16 and a 60/40 Medicaid split you're generating ~2k per day? This obviously isn't accounting for intakes or discharges, just trying to get a basic idea.
Yes that is about what you generate for those patients for both codes medicare and PPOs dont pay much more for therapy around the top end $80 for the +16 min code and it is the same time range for inpatient v OP for the add on code.
Remember not all patients will get a therapy code as some will be not appropriate for therapy. So for a caseload of 15 and accounting for a few admissions and discharges you'd be looking at maybe $1500-1800 take home after accounting for collections issues, some patients not appropriate for therapy etc. Being ok with a higher caseload will greatly be determined by your working team and how good they are at making sure you are only doing true doctor work
I see. So 100+80 for a private patient sounds pretty dang good. Maybe the real question is, how do you find inpatient units with a greater proportion of private patients?
Not the ones I work on though honestly the only patients with private pay that are fun to me are the younger adults that are on parents insurance and going through either their first break or early in illness. I prefer the sicker patients in the hospital its just more fun to me.
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