2021 Recruiting Data and Psychiatry

[AD04]

I found an interesting publication from Merritt Hawkins which discusses recruiting based on last year's data:

https://www.merritthawkins.com/uploadedFiles/physician-advanced-practitioner-incentive-review-2021.pdf

- p. 6: Demand for ARNPs (through MH) has been increasing especially in the last 2 years while demand for FM, IM, psychiatry, and dermatology has been decreasing year after year. Possible evidence for mid-levels replacing certain specialties on a nationwide scale?

- p. 6: Demand for almost all physicians went down due to COVID.

- p. 9: The HIGH range of psychiatry is relatively low compared to other specialties. I'm shocked at how low it is.

- p. 20: Residents are receiving less recruiting offers since 2011 to now. Offers are likely are going to mid-levels.

- p. 34: Psychiatry's salary was minimally affected by COVID while most specialties' salary dropped. Maybe because it is relatively easy to transition to telepsychiatry.

Maybe those who were warning us about mid-levels might have merit, especially given the data.

Did COVID speed up the takeover by mid-levels? Or is it transient? Your thoughts?

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[Ole_Toe]

Isn't this saying psychiatry is still top 5 in specialty demand - both in relative and absolute terms? There's even an entire section on the increasing need for psychiatrists. Also Pg. 13 - avg salary in NE and SW was > 300k. Definitely an expansion of NPs, which shouldn't surprise anyone who spends any time on SDN. But I'm not sure that any of the data you posted suggest that there has been a tradeoff negatively effecting demand or compensation of psychiatrists.

 

[AD04]

Isn't this saying psychiatry is still top 5 in specialty demand - both in relative and absolute terms? There's even an entire section on the increasing need for psychiatrists. Also Pg. 13 - avg salary in NE and SW was > 300k. Definitely an expansion of NPs, which shouldn't surprise anyone who spends any time on SDN. But I'm not sure that any of the data you posted suggest that there has been a tradeoff negatively effecting demand or compensation of psychiatrists.

Less than 5 years ago, psychiatry was number 2 or number 3, after FM. Page 6 shows decrease demand.

 

[thepoopologist]

Hard to say.


Factors to consider:

Covid's impact during and after pandemic is over

The number of current psychiatrists

The number of psychiatry residents

The number of NP and NP students headed into psychiatry and how the training evolves (will they ever be trained to the point where they can adequately handle say 80% of what's out there or is their fight more about marketing vs competency)

NP independent states

Insurance reimbursements for NP vs psychiatry

Organizations which are more profit driven

Organizations which are more liability avoidant (more government)

Organizations that emphasize good psychiatric care (hahahahahahaha)

Organizations who respond to the job market

Organizations who do not respond to the job market and remain firm in their comp and duties

Different practice settings and whether the organization values psychiatrists, NPs, or a mix where psychiatrists oversee NPs depending on whether they are more profit driven or liability avoidant

Supply vs demand of each practice setting. For example, telepsychiatry's boom in the midst of an unknown killer virus perhaps driving down rates.

 

[dl2dp2]

Main issue here is that none of the successful PPs owner's total income will be part of the survey. These numbers are "income offered" at facility based jobs. Numbers are within range of what I would expect. I don't think any facility will hire a psychiatrist and pay $500k a year. The math just doesn't work out.

 

[justordinary]

Main issue here is that none of the successful PPs owner's total income will be part of the survey. These numbers are "income offered" at facility based jobs. Numbers are within range of what I would expect. I don't think any facility will hire a psychiatrist and pay $500k a year. The math just doesn't work out.

Do you think this might mean that there is decreasing job security for psychiatrists who are employed by facilities, and opening PP is means more protection?

 

[dl2dp2]

Do you think this might mean that there is decreasing job security for psychiatrists who are employed by facilities, and opening PP is means more protection?

No. I have heard of stories on the interwebs where supposedly a psychiatrist (often a woman) gets laid off and replaced by an NP, but I think in general most psychiatrists hired by a facility generates too much value to be laid off in the majority of circumstances due to financial reasons. These stories usually imply that the MD occupied a cost center (i.e. a facility job that loses money). In general, facilities would just underpay you or never give you raises if they really want you out. People get fired, but usually for fault (or some other issue, like stop showing up to work, etc). As long as you are revenue generating, you have absolute job security. But very often the job itself for a variety of reasons is ****ty.

PP isn't for everyone. Many people don't have the business acumen or the appropriate credential to succeed. PP also is heterogeneous and have various segments, so you need a product-market fit. In general starting your own business is "less safe" in the sense of income variance. In psychiatry, the risk is more asymmetrical favoring everyone starting a practice, as the startup and maintenance cost is minimal. The main cost if you fail at PP (which typically means you can't fill, or not at the rate you want) is opportunity cost, which means you'll need to live like a resident or take moonlight part time gigs, which are very plentiful in this field, and the limited hours make even a ****ty gig more tolerable. But it's never the case where you need to take on personally guaranteed large debt load as in procedural specialties, so starting a PP in psychiatry in and of itself will rarely bankrupt you.

 

[Sushirolls]

Do you think this might mean that there is decreasing job security for psychiatrists who are employed by facilities, and opening PP is means more protection?

Yes.

And Sluox is right, too.

 

[Sushirolls]

**Winter is Coming**

Your dragon glass is opening your own private practice or becoming the medical director for a Big Box organization and running the gauntlet of signing off on every ARNP, attending countless meetings, shoe licking, and containing any desire to rock the boat or change anything of real consequence.

 

[deleted456421]

I already knew NPs were being heavily recruited, but I didn't realize how dramatically their salaries have increased. From the link: "Average starting salaries for NPs showed strong growth, increasing 12% year-over-year, from $125,000 to $140,000."

Wonder if some of it had to do with nursing shortages from Covid driving up compensation for bedside nursing, which drove down the supply of those willing to work as NPs.

 

[justordinary]

I already knew NPs were being heavily recruited, but I didn't realize how dramatically their salaries have increased. From the link: "Average starting salaries for NPs showed strong growth, increasing 12% year-over-year, from $125,000 to $140,000."

Wonder if some of it had to do with nursing shortages from Covid driving up compensation for bedside nursing, which drove down the supply of those willing to work as NPs.

I think that is one of the factors contributing but it's probably more about the money, plus nursing lobby.

 

[deleted456421]

I think that is one of the factors contributing but it's probably more about the money, plus nursing lobby.

Probably. Just realized PA salaries increased similarly.

 

[dl2dp2]

Yes.

And Sluox is right, too.

I do really think winter is coming for certain facility-based jobs that are known to lose money that aren't too high liability. I.e. CL, Medicaid-based outpatient. Facilities will push out elements that they don't like, with the excuse that we are losing too much money. Meanwhile, given the plethora of NPs, they can use NPs to see most cases and then force staff MDs to supervise the NPs. The question here isn't how we keep MDs because they make us money but how we can cut people so we lose less.

Inpatient facilities/ERs are often overstaffed 10 years ago and now the reliance on NPs/trainees is making these jobs less desirable. The prevailing practice though is still that MDs need to final signoff. This could change, but I don't see how, as very often the state mandates physician eye on involuntary patients. The nursing lobby is trying to gut that law, to a varying degree of success.

 

[justordinary]

I do really think winter is coming for certain facility-based jobs that are known to lose money that aren't too high liability. I.e. CL, Medicaid-based outpatient. Facilities will push out elements that they don't like, with the excuse that we are losing too much money. Meanwhile, given the plethora of NPs, they can use NPs to see most cases and then force staff MDs to supervise the NPs. The question here isn't how we keep MDs because they make us money but how we can cut people so we lose less.

Inpatient facilities/ERs are often overstaffed 10 years ago and now the reliance on NPs/trainees is making these jobs less desirable. The prevailing practice though is still that MDs need to final signoff. This could change, but I don't see how, as very often the state mandates physician eye on involuntary patients. The nursing lobby is trying to gut that law, to a varying degree of success.

... This scares me...
I work in an academic outpatient facility that treats a LOT of medicare/medicaid patients. My facility is hiring more and more NPs, less MDs, is slashing MD salaries and bonuses, and then starts NP "residency" program and also recruits NP for 80% of physician salary!!

All the more reason that i have to jump ship and save myself...

 

[dl2dp2]

... This scares me...
I work in an academic outpatient facility that treats a LOT of medicare/medicaid patients. My facility is hiring more and more NPs, less MDs, is slashing MD salaries and bonuses, and then starts NP "residency" program and also recruits NP for 80% of physician salary!!

All the more reason that i have to jump ship and save myself...

OOOH yeah lol. These are not good signs. You need to be on the job market yesterday.

Btw, Medicaid isn't in and of itself a death sentence. There are highly profitable businesses predicated on treating only Medicaid patients, and not to say the plethora of "non-profits" that end up giving the physician-executive director very high salaries. But you need to do know what you are doing and become familiar with the local Medicaid system (i.e. mechanisms to get block grants, channels for lobbying for "carve-outs", "strategic partnerships" with large hospital systems, etc.) It's great fun! I don't know if you played role-playing games when you grew up, but it reminds me of playing Myst, where you basically walk into a jungle without knowing the rules.

PP is way easier in comparison. APA actually literally wrote a book on how to start a PP. Read it and follow the recipe and you'll be winning.

 

[comp1]

I continue to think we're fine, more than that, great! How many centuries are you planning to practice where you actually expect to be impacted by these really slight shifts? How can you pull out anything meaningful when they lump all "nurse practitioners" together while separating out interventional from non-interventional cardiologists? Also, they are tracking what percent of residents receive more than FIFTY offers? How many job offers does one person need? What other industry has anything like that? We are doing so much better than almost the entirety of the rest of the economy. I just do not get the concern.

 

[Sushirolls]

That's good comp1. More data points from peoples experiences/observations, the more informed people can be. When the day comes that you experience certain negatives have change in posting tone, it'll be another warning sign of things progressing.

 

[FlowRate]

From a short-term business finance perspective NP's in independent practice states are like a 95% replacement for psychiatrists. Patients get seen for the same amount of time, get meds, some maybe get better.

Psychiatry is the worst when it comes to trying to figure out useful metrics and so the actual value of a psychiatrist over an NP won't be obvious until really big HMO systems start studying cost outcomes of NP cohorts vs physician cohorts.

 

[MacDonaldTriad]

I have said this many times, but the sky isn't falling. NPs are taking over psychiatry positions only because employers can't find psychiatrists to fill their positions. The majority of them would want to hire grown up psychiatrists who can take on the liability without needing co-signatures / supervision that burdens what few psychiatrists they can get. The job market remains ridiculously strong for residents in psychiatry who complete training. The only reason mid-levels have any inroad into psychiatry is because there are not enough of us. There are plenty of us practicing psychiatry badly, but not as badly as GPs who can't find psychiatry providers and end up doing it themselves.

 

[clausewitz2]

I do really think winter is coming for certain facility-based jobs that are known to lose money that aren't too high liability. I.e. CL, Medicaid-based outpatient. Facilities will push out elements that they don't like, with the excuse that we are losing too much money. Meanwhile, given the plethora of NPs, they can use NPs to see most cases and then force staff MDs to supervise the NPs. The question here isn't how we keep MDs because they make us money but how we can cut people so we lose less.

Some of these places don't even pretend to want to keep MDs anymore. For some reason the CMHC I am leaving has a terrible time finding any replacement MDs and is shedding them constantly. I am sure it has nothing to do with offering 20% less than even other CMHCs in the region. When I told them I was going they asked if there was anything they could do to get me to stay, pro forma. I named three things they could change, none of which involved me getting a dime more, and one of which was pretty simple (give me the resident teaching opportunity you swore up and down I would have when hired that never materialized).

They were not willing to do any of those things. so now the prescription-capable staff is 80% NPs, but they can't even get enough of them. So instead they yank in MDs from other parts of the system to do tele part-time, which only works because the rate they offer seems like incredible generosity compared to the local academic pittance.

joke's on them though, they are burning through new mid-level therapy grads faster than they can churn in new ones so they are going to hit a wall sooner rather than later. Fairly confident by this time next year though the medical director will literally be the only MD.

I agree though that this is probably an issue for places where reimbursements really aren't great and administration is very fixated on maximizing net revenue consequences be damned. It is worth pointing out the CMHC I am referring to has undergone this process after they were devoured and sucked into the local Leviathan system a couple years ago. Lovely place to work prior to that, so I'm told.

 

[Psychferlyfe3000]

I have said this many times, but the sky isn't falling. NPs are taking over psychiatry positions only because employers can't find psychiatrists to fill their positions. The majority of them would want to hire grown up psychiatrists who can take on the liability without needing co-signatures / supervision that burdens what few psychiatrists they can get. The job market remains ridiculously strong for residents in psychiatry who complete training. The only reason mid-levels have any inroad into psychiatry is because there are not enough of us. There are plenty of us practicing psychiatry badly, but not as badly as GPs who can't find psychiatry providers and end up doing it themselves.

So, do you think that the decrease in demand for psychiatrists is due to factors unrelated to NPs?

 

[MacDonaldTriad]

What decrease in demand for psychiatrists are you aware of? The market is ridiculous and I can't delete head hunters on my email fast enough.

 

[clausewitz2]

What decrease in demand for psychiatrists are you aware of? The market is ridiculous and I can't delete head hunters on my email fast enough.

A single job board site got its hands on my personal phone number at some point. The volume of recruiter texts I get daily makes me seriously consider changing my number.

 

[90833]

Just keep working toward FIRE. Financial independence or retirement resolves many of these stressors.

 

[EmilKraepelin55]

**Winter is Coming**

Your dragon glass is opening your own private practice or becoming the medical director for a Big Box organization and running the gauntlet of signing off on every ARNP, attending countless meetings, shoe licking, and containing any desire to rock the boat or change anything of real consequence.

Sounds like a ****ing travesty. I’m in /s

 

[Psychferlyfe3000]

What decrease in demand for psychiatrists are you aware of? The market is ridiculous and I can't delete head hunters on my email fast enough.

The decrease in demand described in OP's post: "demand for FM, IM, psychiatry, and dermatology has been decreasing year after year."

 

[Username2015]

I found an interesting publication from Merritt Hawkins which discusses recruiting based on last year's data:

https://www.merritthawkins.com/uploadedFiles/physician-advanced-practitioner-incentive-review-2021.pdf

- p. 6: Demand for ARNPs (through MH) has been increasing especially in the last 2 years while demand for FM, IM, psychiatry, and dermatology has been decreasing year after year. Possible evidence for mid-levels replacing certain specialties on a nationwide scale?

- p. 6: Demand for almost all physicians went down due to COVID.

- p. 9: The HIGH range of psychiatry is relatively low compared to other specialties. I'm shocked at how low it is.

- p. 20: Residents are receiving less recruiting offers since 2011 to now. Offers are likely are going to mid-levels.

- p. 34: Psychiatry's salary was minimally affected by COVID while most specialties' salary dropped. Maybe because it is relatively easy to transition to telepsychiatry.

Maybe those who were warning us about mid-levels might have merit, especially given the data.

Did COVID speed up the takeover by mid-levels? Or is it transient? Your thoughts?

Thanks for sharing the useful report.

Overall, it seems like demand for psychiatry is incredibly high based on what this report says. Keep in mind that although NPs were the number one most searched for role according to the report, it isn’t clear what percentage of those NP searches were for psychiatric roles.

What is concerning is the following:
“Increasingly, NPs and PAs are viewed as appropriate leaders of the team-based care model, capable of coordinating the efforts of all members of the team, from physicians to community care coordinators. They also are being groomed for those leadership positions considered critical to the transition to quality-based care, including chief quality officer, director of population health management, and others.”

How to deal with this? I’m not sure but have considered:
-Getting politically active
-Avoiding the system via private practice
-Earning and saving as much as I can to prepare for when jobs are less plentiful and compensation decreases

 

[AD04]

Demand for psychiatrist at the moment is still high. Psychiatrists should have no problem getting a job. But to think that mid-levels are not replacing physicians is like an ostrich with its head in the dirt. Search requests for many physicians, including psychiatrists have gone down. Income offered to many physicians has gone done. Search requests for ARNPs and income offered to ARNPs have gone up. No one knows what the equilibrium point will be.

But even if it gets really bad for psychiatrists, those who are adaptable (not just book smart) and can deliver results (e.g. generate revenue) will always have offers.

This is what I am currently doing or have done:
- be a linchpin and become hard to replace (which includes developing clinical skills that generate revenue or business skills which can grow the organization, delivering on what I say I would do, not doing work unless I get paid for it)
- have alternatives to my current job (which is why I got private practice experience because I will always have that option of opening my own shop, learning how to find and negotiate high paying jobs)
- develop other sources of income outside psychiatry (I am already financially independent but I work because I want to)

The older generation of physicians capitalized on the mid-levels and the younger generation will have to deal with the aftermath. Who is going to selflessly crusade to reverse the trend through politics for the benefit of all physician when that person can work hard for himself or herself?

 

[Sushirolls]

Even being a linchpin in an organization means nothing. I built up an ECT service from scratch. Founded a suboxone clinic in an area that was worst for big geographic zone. A couple other key things, too. Didn't stop the Big Box shop from dumping a load of Scat on me or not stepping up to provide things they were obligated to, or provide new resources to expand these services. I was once a believer of linchpin... but Big Box shops just don't care.

The best idea I have been mulling around, is simply opening up a multispecialty clinic, with goals to eventually increase in size to be like a wannabe CCF / Mayo, but right from the start advertise unabashedly this is a physician only organization. All adds reflect its physician only how quality matters. Repetition of advertising and visibility of the group practice could lead to positive changes in time. The structure of the clinic would have to also be highly physician positive with pay structure and not opportunistic.

 

[calvnandhobbs68]

Even being a linchpin in an organization means nothing. I built up an ECT service from scratch. Founded a suboxone clinic in an area that was worst for big geographic zone. A couple other key things, too. Didn't stop the Big Box shop from dumping a load of Scat on me or not stepping up to provide things they were obligated to, or provide new resources to expand these services. I was once a believer of linchpin... but Big Box shops just don't care.

The best idea I have been mulling around, is simply opening up a multispecialty clinic, with goals to eventually increase in size to be like a wannabe CCF / Mayo, but right from the start advertise unabashedly this is a physician only organization. All adds reflect its physician only how quality matters. Repetition of advertising and visibility of the group practice could lead to positive changes in time. The structure of the clinic would have to also be highly physician positive with pay structure and not opportunistic.

I think this is the way private practices will end up having to market themselves. Basically be as anti-NP as NP organizations are anti-MD/DO. Say that you’re “always guaranteed to see a physician, never a nurse” for your care. You already see this on billboards sometimes. Appeal to the segment of the population this matters for (hint: the segment with money/good insurance).

You just have to be willing to burn the NP bridge to do this because for some reason it’s politically incorrect now to be anti-NP in any way shape or form. Give any argument against NP role expansion or comment about how they’re being hired at an academic center/community health agency instead of physicians and you’re pretty much exiled. There are a lot of reasons for this, but you’re basically labeled as not being for “team based care” since midlevels are such an essential part of the “team”. A lot of young doctors without a lot of financial/political power in an organization yet are scared to do this overtly (including myself at times).

 

[nexus73]

I think this is the way private practices will end up having to market themselves. Basically be as anti-NP as NP organizations are anti-MD/DO. Say that you’re “always guaranteed to see a physician, never a nurse” for your care. You already see this on billboards sometimes. Appeal to the segment of the population this matters for (hint: the segment with money/good insurance).

You just have to be willing to burn the NP bridge to do this because for some reason it’s politically incorrect now to be anti-NP in any way shape or form. Give any argument against NP role expansion or comment about how they’re being hired at an academic center/community health agency instead of physicians and you’re pretty much exiled. There are a lot of reasons for this, but you’re basically labeled as not being for “team based care” since midlevels are such an essential part of the “team”. A lot of young doctors without a lot of financial/political power in an organization yet are scared to do this overtly (including myself at times).

Being anti NP in psychiatry, in my experience, is 90% of the time perceived as being anti woman, because there's so few men rn's and few men rn's who go onto be nps. It seems different for crnas or fnp who go onto work certain specialties like cards or surgery. But psych nps are almost all women. Also, being anti-np is bad for business if you're employed at a mega healthcare system, so you gotta tread lightly.

 

[AD04]

Even being a linchpin in an organization means nothing. I built up an ECT service from scratch. Founded a suboxone clinic in an area that was worst for big geographic zone. A couple other key things, too. Didn't stop the Big Box shop from dumping a load of Scat on me or not stepping up to provide things they were obligated to, or provide new resources to expand these services. I was once a believer of linchpin... but Big Box shops just don't care.

You can't get blood out of a stone. Some places just don't have the ability to pay and nothing you do can get them to pay. (Which is why I'm so big on screening before going on site visits.) You can be the best psychiatrist in the world but if you are limited in who you will work for, you won't get the best offers. Being willing to relocate opens many more options.

That's why beautiful women want to move away from home and usually to major cities. That's where they'll have the best chance to capitalize on their beauty and land a successful mate.

Being anti NP in psychiatry, in my experience, is 90% of the time perceived as being anti woman, because there's so few men rn's and few men rn's who go onto be nps. It seems different for crnas or fnp who go onto work certain specialties like cards or surgery. But psych nps are almost all women. Also, being anti-np is bad for business if you're employed at a mega healthcare system, so you gotta tread lightly.

It's so non-PC, but so true. I love it.

 

[Trismegistus4]

You just have to be willing to burn the NP bridge to do this because for some reason it’s politically incorrect now to be anti-NP in any way shape or form. Give any argument against NP role expansion or comment about how they’re being hired at an academic center/community health agency instead of physicians and you’re pretty much exiled. There are a lot of reasons for this, but you’re basically labeled as not being for “team based care” since midlevels are such an essential part of the “team”. A lot of young doctors without a lot of financial/political power in an organization yet are scared to do this overtly (including myself at times).

At my residency there were bleeding-heart liberal reasons behind this, too. I.e., "there just aren't enough psychiatrists to staff community mental health agencies, so we need NPs so that the indigent seriously mentally ill can get their meds."

 

[robellis]

Being anti NP in psychiatry, in my experience, is 90% of the time perceived as being anti woman, because there's so few men rn's and few men rn's who go onto be nps. It seems different for crnas or fnp who go onto work certain specialties like cards or surgery. But psych nps are almost all women. Also, being anti-np is bad for business if you're employed at a mega healthcare system, so you gotta tread lightly.

This is so true..it’s always woman who get upset about being anti-NP I’ve been so many arguments and it’s literally always a woman