Academic Salary Naïveté

[Geodont]

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I’ve been out of training for years and am a little embarrassed to ask…Are most academic salaries truly non negotiable?

I’m looking in high saturation coastal markets (yes that’s the key detail)… but the least negotiable are the ones that sound the most desperate for unpopular outpatient gigs. I mean, daily post interview follow-ups of, “do you want us?”

Perhaps desperate because these positions are especially unpopular in high cost-of-living settings that come along with such markets…So what gives?
I find them totally unwilling/unable to budge a single cent even when negotiating less pay/hours than their 40hr/wk max “salary ceiling.”

Any tips or strategies to try?

 

[Ironspy]

Salaries have minimal negotiation. You can negotiate to start at a higher tier at some places based on your experience or training but the salary at each tier is pretty fixed. That’s why many of these places have trouble hiring. They will advertise a salaried position that pays 190k/year for years while paying a locum $275/hour to fill it in the meantime without considering an increase in the salary.

 

[whopper]

You can certainly negotiate but in doing so you need to think to yourself what are you worth and what assets do you bring as bargaining chips. Also while you can negotiate the department's ability to pay you more is also not extremely fluid. They may have budget constraints, have to go through higher channels, etc.

 

[MacDonaldTriad]

If you were on a mission to find the employer that had the least ability to adapt to market values and a budget that doesn't understand the need to keep up with a fluid job competition, you would easily conclude that academics are the best answer. For more than 30 years, our graduates out earn me and I signed up knowing this. It is safe to say that graduates who earn a lot are willing to go into the factory jobs that want visits Q20 min or Q 15 min, and have no control of their schedules with a slave driver on a Roman galley ship with oars filling in their schedules.

If you can feather a bed at a university and put up with the pay and enjoy teaching enough to be comfortable but less rich, go for the academic job. Stop doing algebra with what could be and see this as apples and oranges. Money is one comparator, but is is more minor than you might think. At least there are too many psychiatrists that use this as a yard stick that dominates more than it should and then find themselves miserable on the treadmill. Is that extra $20 - 30k worth the misery? Even if it is $100K, you can live under your means and do well without killing yourself.

I'm familiar with the Beetle's "money can't buy every thing it is true, but what it can't buy, I can't use". Or the trite "money can't buy happiness". I heard a great one last night watching the last season of "Norsemen" (I highly recommend it as it is Vikings meet Monty Python" comedy, on Netflix) and someone said, "Silver isn't important as long as you have enough of it".

Every time you insert that debut card into a reader, your retirement date moves further from you on the treadmill you agreed to get on.

 

[Celexa]

Negotiate on other aspects of your contract, not salary. Admin and teaching time, call, etc.

 

[splik]

This is a complicated question. The short answer is there is usually very little, if any, room to negotiate salary. However it also depends on if you are talking public vs private, and the location. Private institutions in undesirable locations may have more flexibility. There may be other things you can negotiate including a sign-on bonus, relocation expenses, green card sponsorship, % of protected time, title, CME budget etc.

There was a time when there was a good trade off between the pay and the benefits of the jobs (including job security, a good pension, lots of professional leave, generous sick leave, lots of time for teaching, research time and funding, reduced patient load, longer patient appointments). Unfortunately nowadays there are usually wRVU targets. Some places the wRVU targets are so ridiculous for what the pay is that they rival the grinding of big box shops. You definitely want to avoid that kind of thing.

Also, remember in order to negotiate you need to have leverage. The first rule is you almost certainly need to show a job offer at another academic institution where they will pay you more. It probably won't help much if you say some place that is non-academic is offering you more because that is expected.

I have heard, very occasionally of people getting a significant bump in salary just by asking (but the bump is still to well below median pay). However that is the exception that proves the rule.

 

[FlowRate]

I can say that I definitely heard a range of salaries for residents negotiating with our academic centers coming out of training. The range wasn't huge but maybe 20k wiggle room? The other negotiating pieces were non-financial (office space, schedule specifics, protected time, service line, etc.)

 

[Geodont]

Salaries have minimal negotiation. You can negotiate to start at a higher tier at some places based on your experience or training but the salary at each tier is pretty fixed. That’s why many of these places have trouble hiring. They will advertise a salaried position that pays 190k/year for years while paying a locum $275/hour to fill it in the meantime without considering an increase in the salary.

I guess they bank on the transience of locums and the absence of benefits owed. In less desirable locations, I’ve definitely run into “grandfathered” locums folk still lingering on at $300/hr.

 

[Geodont]

The gig I’m looking at is a FQHC (federally qualified health center) overseen by an academic institution. Mix of outpatient SMI telepsych (10 pts minimum a day but can schedule 18)…and some care coordination days (review PCP charts only).

I’m not sure what other dynamics are at play if any with the federal funding. 40hr/week is 240K but they won’t do 215K on 30hrs. They came back at a strictly proportionate 192K w/ 5K sign on vs moving expenses.

I want at least 200K. Worth a try even? For comparison, an academic outpatient gig in the same city got me 200K at 40hrs/wk in 2018.

There’s no call and no private practice restrictions (no competes- which aren’t enforceable in my state anyway). Not much else to negotiate. They have ER moonlighting at 12hr shifts for 250/hr and said they could guarantee some availability.

I’m only doing this to myself because I have 24 months of PSLF left, assuming it’s even real.

 

[splik]

The gig I’m looking at is a FQHC (federally qualified health center) overseen by an academic institution. Mix of outpatient SMI telepsych (10 pts minimum a day but can schedule 18)…and some care coordination days (review PCP charts only).

I’m not sure what other dynamics are at play if any with the federal funding. 40hr/week is 240K but they won’t do 215K on 30hrs. They came back at a strictly proportionate 192K w/ 5K sign on vs moving expenses.

I want at least 200K. Worth a try even? For comparison, an academic outpatient gig in the same city got me 200K at 40hrs/wk in 2018.

There’s no call and no private practice restrictions (no competes- which aren’t enforceable in my state anyway). Not much else to negotiate. They have ER moonlighting at 12hr shifts for 250/hr and said they could guarantee some availability.

I’m only doing this to myself because I have 24 months of PSLF left, assuming it’s even real.

This isnt a real academic position. The main issue here is that the contract the FQHC has is with the academic center. They are going to take at least 20% cut from that contract so there is less for your salary than if you just worked for the FQHC directly.

 

[calvnandhobbs68]

The gig I’m looking at is a FQHC (federally qualified health center) overseen by an academic institution. Mix of outpatient SMI telepsych (10 pts minimum a day but can schedule 18)…and some care coordination days (review PCP charts only).

I’m not sure what other dynamics are at play if any with the federal funding. 40hr/week is 240K but they won’t do 215K on 30hrs. They came back at a strictly proportionate 192K w/ 5K sign on vs moving expenses.

I want at least 200K. Worth a try even? For comparison, an academic outpatient gig in the same city got me 200K at 40hrs/wk in 2018.

There’s no call and no private practice restrictions (no competes- which aren’t enforceable in my state anyway). Not much else to negotiate. They have ER moonlighting at 12hr shifts for 250/hr and said they could guarantee some availability.

I’m only doing this to myself because I have 24 months of PSLF left, assuming it’s even real.

SMI + telepsych = hope you have good case managers/social workers. This also better not be production based at all because the no show rate for the FQHC SMI population will likely be abysmal. How much vacation and stuff are you getting? Are they giving you any charting time or admin time or anything? 197K (your first year) / 30*48 weeks (1440) = 136.8/hr which is pretty bad if you're looking at it on an hour by hour basis.

 

[comp1]

Outside of a straight up private practice that you're joining, salaries aren't negotiable a lot of places. The bigger the place, the less negotiation. Salaries are set by boards hundreds of miles away from whoever you are interviewing with and they're based on local averages, not anything about you in particular. Definitely concur with negotiating the job specifics, not the salary. That said, if you want to teach, there are LOTS of ways to do that and not take quite the major salary hit that you do in full academics. Consider the VA or becoming a volunteer clinical faculty. Most state or county jobs would probably be okay with you having a resident or med student tagging along.

 

[Geodont]

This isnt a real academic position. The main issue here is that the contract the FQHC has is with the academic center. They are going to take at least 20% cut from that contract so there is less for your salary than if you just worked for the FQHC directly.

I hadn’t thought of it that way (the cut). There’s an academic position (faculty) attached to it, but I’ve only ever taken those when they come w/the package anyway (could care less).

 

[Geodont]

SMI + telepsych = hope you have good case managers/social workers. This also better not be production based at all because the no show rate for the FQHC SMI population will likely be abysmal. How much vacation and stuff are you getting? Are they giving you any charting time or admin time or anything? 197K (your first year) / 30*48 weeks (1440) = 136.8/hr which is pretty bad if you're looking at it on an hour by hour basis.

No dedicated admin time that I know of. Most people use the hour of lunch or incorporate 3x20 min intervals. 1.5hrs new intake, 20 min f/u. They mentioned using “copy forward” in Epic and celebrate that their target is 10 pts a day. They schedule 13-18 to hit the target. God forbid all 18 noncompliant SMI’s show up. Apparently RVU’s are for bonus purposes only, but I’m sure I’d get grief if I fell below 10/day. Vacation is 25 days/yr at 40hrs/wk and 20 at 32hrs/wk.
I wondered the same, how does tele work with SMI’s w/o CM or SW. Pt’s all have a SWer, but they like to focus on counseling these pts apparently.

They initially told me 15% SMI but a person who left them (and who swore they loved the job), said it’s more like 80%. Oh and add interpreters to this tele picture (community is a mix of Cantonese and Spanish speaking).

Mind you, I’m years removed from SMI (some “Dec and discharge” in the ER but no outpatient SMI contact since residency). That said, I prefer urban SMI to more entitled populations. I think 32hrs/wk will be 1-3 days SMI and bread/butter outpatients with 1 or 2 days collaborative care consults (4 days/wk total).

Will most academic centers be willing to write letters of intent outlining roles/responsibilities, title, salary, contract term before a contract is sent? My first job out of fellowship, I made the HUGE mistake of taking an academic outpatient position where I signed a contract stating, “the usual roles and responsibilities of a psychiatrist at X medical center.” Turns out they tried to incorporate CL too.

 

[Merovinge]

it’s more like 80%. Oh and add interpreters to this tele picture (community is a mix of Cantonese and Spanish speaking).

Yeahhhh, bless you for considering taking on this work. It's badly needed but SMI through tele AND interpreter is going to be real tricky. SMI in-person w/ an interpreter was already so tough.

 

[nexus73]

This job sounds like garbage. If the location is highly desirable I get it, but otherwise this stinks. 30-32 patient facing hours per week is the new full time, with 8-10 hours admin/documentation time built into the day. If there are so many no shows that you have 10 patients per day, maybe that's ok. BUT the bonus structure should be set up differently, like an extra $120 for every patient over 10 in a given day, and no penalty for less than 10 per day. However, I'd be shocked if they ever offered something like this.

Our local FQHC, no academic affiliation, not in a major metro area: 260-280K, 4 day week x 8 patient hours is full time, take Friday off. SMI population. There are better jobs, but they qualify for NHSC loan repayment if you have loans. And they are in desperate need of psychiatrists.

 

[Geodont]

This job sounds like garbage. If the location is highly desirable I get it, but otherwise this stinks. 30-32 patient facing hours per week is the new full time, with 8-10 hours admin/documentation time built into the day. If there are so many no shows that you have 10 patients per day, maybe that's ok. BUT the bonus structure should be set up differently, like an extra $120 for every patient over 10 in a given day, and no penalty for less than 10 per day. However, I'd be shocked if they ever offered something like this.

Our local FQHC, no academic affiliation, not in a major metro area: 260-280K, 4 day week x 8 patient hours is full time, take Friday off. SMI population. There are better jobs, but they qualify for NHSC loan repayment if you have loans. And they are in desperate need of psychiatrists.

No base salary penalty for less than 10. UP to 20K bonus range for stuff like buprenorphine if you get a DEA X, checking A1C’s, taking a joke call, and hitting certain productivity targets (prorated at 32hrs but so is the bonus). Location is desirable and NHCS qualifying at the same time. Hey graduation season is here, so plenty of newcomers to swoon if I don’t take it. Maybe that’s why I have little bargaining power. If they won’t do 200K, 1/2 day admin out of 4 days is fair.

 

[calvnandhobbs68]

No base salary penalty for less than 10. UP to 20K bonus range for stuff like buprenorphine if you get a DEA X, checking A1C’s, taking a joke call, and hitting certain productivity targets (prorated at 32hrs but so is the bonus). Location is desirable and NHCS qualifying at the same time. Hey graduation season is here, so plenty of newcomers to swoon if I don’t take it. Maybe that’s why I have little bargaining power. If they won’t do 200K, 1/2 day admin out of 4 days is fair.

I doubt many new graduates are gonna be "swooning" over this job, so don't sell yourself short. I mean seriously, even if you have 300K of student loans, they can go into private practice, make 100K+/year over what this job will pay for easier work and pay off the loans in 3-4 years if they're serious about it and not have to deal with all the headaches from this job. Only plus seems to be that you'll get a 1-2 easier days a week of collaborative care stuff with PCPs, which could be interesting and definitely a bit easier. If you can't get them to budge on salary, I agree make them give you some admin time at least.

This is for real like mother teresa level stuff you're doing here, FQHC SMI population through telepsych with interpreters? I don't know how you get a more difficult outpatient setup just from a case management standpoint, which makes it even more concerning that their social workers/case managers are not doing actual case management with these patients. I used to work in a clinic with a primarily homeless SMI population in residency and kind of half the point of our visits were that their case manager would often bring them to the appointment, they could fill their meds at the on site pharmacy and their case manager/social worker could help them with other social stuff that was going on.

 

[Geodont]

I doubt many new graduates are gonna be "swooning" over this job, so don't sell yourself short. I mean seriously, even if you have 300K of student loans, they can go into private practice, make 100K+/year over what this job will pay for easier work and pay off the loans in 3-4 years if they're serious about it and not have to deal with all the headaches from this job. Only plus seems to be that you'll get a 1-2 easier days a week of collaborative care stuff with PCPs, which could be interesting and definitely a bit easier. If you can't get them to budge on salary, I agree make them give you some admin time at least.

This is for real like mother teresa level stuff you're doing here, FQHC SMI population through telepsych with interpreters? I don't know how you get a more difficult outpatient setup just from a case management standpoint, which makes it even more concerning that their social workers/case managers are not doing actual case management with these patients. I used to work in a clinic with a primarily homeless SMI population in residency and kind of half the point of our visits were that their case manager would often bring them to the appointment, they could fill their meds at the on site pharmacy and their case manager/social worker could help them with other social stuff that was going on.

Unfortunately my loan debt is in the 480K range and I rely on a single income. I missed out on so many 300K+ jobs for PSLF’s sake (and my kind heart).
But with only 2 out of 10 years to go…
A couple states are suing FedLoan (the servicer) on the east coast at least, so hopefully PSLF forgiveness comes to easier fruition.

Verbally, this gig told me they can give most of the SMI’s to other candidates who are really into them. I sense most of their population IS SMI though. I was honest about not having managed this population continuously since residency. I will have to rely on uptodate for LAI and Cloz refreshers. For what it’s worth, the psychiatrist who left was in private practice for 20+ years before doing this for 7 years (for benefits) and he managed after a steep learning curve. Thing is, with tele it’s harder to access colleagues in real time too.

It’d probably be hard to get their SMI reducing offer in writing.

 

[whopper]

Said this before.
Academia is a good route right after graduation and it's cause most residents still haven't learned enough. Stay and absorb for another year or two. While in academia, if it's your plan to leave this will give you breathing room to get your chess pieces in play for something else. So if it's private practice you'll have to learn how to do things such as get a biller, find an optimal EHR, scout out locations and other practices in the area.

 

[comp1]

Looking at the later post from the OP...this is not really an academic job. This is a county outpatient job with some sort of educational supervision on the side. It also sounds bad, but I've not liked outpatient much at all, ever, so I have a hard time judging.

 

[Geodont]

Update: They wouldn’t (or couldn’t) budge (at all) on salary or any actual admin time (beyond using one’s lunch hour). This one has been checked off the list. There was also a glaring red flag of “15% SMI” vs “80%” depending on who was answering questions. Oh, and 2 people leaving in 6 months…
I appreciate everyone’s guidance! My gut kept saying “no” but the location and benefits were temping (in spite of the insane cost of living). I would reiterate, however cliche, the advice of not selling oneself short (especially to those of us only 5-6 years out).

 

[hallowmann]

Verbally, this gig told me they can give most of the SMI’s to other candidates who are really into them. I sense most of their population IS SMI though. I was honest about not having managed this population continuously since residency. I will have to rely on uptodate for LAI and Cloz refreshers. For what it’s worth, the psychiatrist who left was in private practice for 20+ years before doing this for 7 years (for benefits) and he managed after a steep learning curve. Thing is, with tele it’s harder to access colleagues in real time too.

It really depends on what they're defining as SMI. If they are saying 15% is psychotic disorder/bipolar 1, that might be true, but knowing its an FQHC there's probably a lot of SMI in the form of dual-diagnosis, PTSD, and personality disorder.

Is this pure Tele? If so that does add some money saved on transportation and time, which in highly desirable areas can really add up (like 5-8 hr drives, 2 gal of gas a day, etc.). High SMI, high language barrier, and low pay honestly seems like you can do better even in desirable location.

Looking at the later post from the OP...this is not really an academic job. This is a county outpatient job with some sort of educational supervision on the side. It also sounds bad, but I've not liked outpatient much at all, ever, so I have a hard time judging.

Exactly, this sounds like a county job with academic affiliation (which most of them have). I think the biggest thing here is the pay to hour ratio is pretty poor. There are county jobs paying more.

 

[Geodont]

It really depends on what they're defining as SMI. If they are saying 15% is psychotic disorder/bipolar 1, that might be true, but knowing its an FQHC there's probably a lot of SMI in the form of dual-diagnosis, PTSD, and personality disorder.

Is this pure Tele? If so that does add some money saved on transportation and time, which in highly desirable areas can really add up (like 5-8 hr drives, 2 gal of gas a day, etc.). High SMI, high language barrier, and low pay honestly seems like you can do better even in desirable location.



Exactly, this sounds like a county job with academic affiliation (which most of them have). I think the biggest thing here is the pay to hour ratio is pretty poor. There are county jobs paying more.

100% true about subjectivity in defining SMI. For those of us long removed from that world, my simple rule of thumb to self is LAI+++ (substance, personality, complex PTSD).
100% a county setting without the added academic institution hyena substrate would have paid more… and maybe even not been so stingy about admin time (well maybe they would be actually, but they’d pay more).
Numerous colleagues that do FQHC work in urban and rural areas told me SMI’s are a smaller fraction of their caseloads.

Yes, it was all tele which does add value. However predominantly SMI tele w/o at least an ACT team (and w/interpretation needs) is not worth 192K at 4 days a week…well 1 or 2 days would allegedly be collaborative care, but in this setting it sounded like adding a ton of PCP drama to the mix rather than casually making recs based on chart review.

Not sure if others consider this a 🚩, but when clinic supervisors/leadership are all very recent graduates (along with enough regular attendings), it gives me the impression they are subsisting on the young and energetic in a labor intensive setting (as most who left were later career folk, but didn’t retire).

What put me off the most is that they refused to define the role clearly (ie “2 days of general outpatient and 2 days of collaborative care consults”). It was like, “Well we’ll see what Dr So-and-So who currently wants to CUT BACK on collaborative care thinks…So have you decided yet?!”
Gimme a break.
Plus it sounded like their federal grant for collaborative care was time-limited or just a pilot program anyway.

…There’s a poster on this thread saying 4 days/wk is the new full time norm now with 1 admin day at such settings, but I don’t find that to be the case in higher cost of living cities.

And heck, I have nothing to hide. This was in NYC with Manhattan academic center affiliation. It used to be a freestanding community health center for decades and it seems various psychiatrists left when the academic affiliation finalized. 🚩
Years ago I stopped practicing in NYC due to the medical-academic-corporate complex becoming unbearable. I would never sell my soul to such a model at fulltime, but if it would give me a base salary while building private practice (in the absence of enforceable no competes), maybe.

 

[Celexa]

Ha. NYC definitely explains why what you were describing was so vastly different from what my peers reported in their job searches this year. The grass is certainly greener elsewhere....

 

[Geodont]

NYC does factor into reasonably negotiable aspects of a job remaining entirely non negotiable (even at the most desperate sounding places). Lame but true.

 

[dl2dp2]

NYC does factor into reasonably negotiable aspects of a job remaining entirely non negotiable (even at the most desperate sounding places). Lame but true.

There are ways to make a *LOT* of money doing NYC academics (500k+ AND PSLF eligible). Unfortunately, the job you have isn't really going to end you up there and will be a recipe for burnout, and you are not thinking about all of this in the right way strategically.

The typical way to do this is a very chill state/govt/teaching/facility admin job that may pay little but has flexible hours and low clinical duty, then a heavier cash side private practice. There are also other ways, but this is the most typical. Some people end up in a high-paying locum arrangement, but the effect is similar. If PSLF is really the main consideration, and you have a good enough resume to build a PP, I would consider further decrease of the FQHC job to 50% FTE to keep your health insurance and PSLF eligibility. This would be the "right" way to do academics.

If you work 20 hours a week in PP in NYC, you can easily gross 300k on that alone. This is really a lower-bound estimate--that being said, you won't easily fill 20 hours of PP in year 1. OTOH, 20 hours of locum should gross you 200k+, and you can easily fill that in year 1. This should give you 40 clinical hours at total income of 300k+ plus PSLF eligibility in NYC in year 1. If you are enterprising, you should hit 400k in year 2+, with between 40-50 clinical hours. I think this is typical for a single-income "academic" psychiatrist in NYC. After year 2, you complete PSLF, then sky is the limit. A small (but not exceptional) number of academic affiliated psychiatrists in the tri-state area are in the *wealthy* territory (total comp 1M+) doing PURE clinical work, an unusual situation in medicine in general. Some of them even have "full-time" W2 gigs from academic institutions. However, the vast majority of their gross income derives from private clinical work that is separate from their academic activity. Others make more money through developing a private business (i.e. a large private practice with ancillary staff). Still, regardless of the final pathway, most of the money that can be captured in major markets live in the private world.

 

[Geodont]

There are ways to make a *LOT* of money doing NYC academics (500k+ AND PSLF eligible). Unfortunately, the job you have isn't really going to end you up there and will be a recipe for burnout.

The typical way to do this is a very chill state/govt/teaching/facility admin job that may pay little but has flexible hours and low clinical duty, then a heavier cash side private practice. There are also other ways, but this is the most typical. Some people end up in a high-paying locum arrangement, but the effect is similar. If PSLF is really the main consideration, and you have a good enough resume to build a PP, I would consider further decrease of the FQHC job to 50% FTE to keep your health insurance and PSLF eligibility.

If you work 20 hours a week in PP in NYC, you can easily gross 300k on that alone. This is really a lower-bound estimate--that being said, you won't easily fill 20 hours of PP in year 1. OTOH, 20 hours of locum should gross you 200k+, and you can easily fill that in year 1. This should give you 40 clinical hours at total income of 300k+ plus PSLF eligibility in NYC.

I know a plenty of people that did part time academic in NYC for benefits and a “base” until their PP grew stable enough. Many technically also violated obscenely greedy NYC no competes (of their era) in doing so-but the reality is, most hospitals won’t find it worth their legal fees to enforce those (using in house counsel helps). These days, I hear they’re not so enforceable anyway- though they stick them in contracts for good measure…I once had one that said I could never see any patient that had any encounter with any specialty in that entire hospital (no time or geographic limits! hilarious).

Director/admin gigs seem to be such a universally covered end goal in psychiatry (ehem not seeing patients), but those positions are likely subject to NYC nepotism and dog-eat-dog competition (if not nepotism). And word of mouth helps pinpoint the chill admin gigs in NYC (harder to ferret out when you no longer live there). You are so right about the community gig being a burnout recipe… and precisely those who told me they had side PP’s at said gig…were primarily admin-ey/directors.

 

[dl2dp2]

I know a plenty of people that did part time academic in NYC for benefits and a “base” until their PP grew stable enough. Many technically also violated obscenely greedy NYC no competes (of their era) in doing so-but the reality is, most hospitals won’t find it worth their legal fees to enforce those (using in house counsel helps).

There were several discussions on this topic. Just to be clear, what you are talking about is not a "non-compete", which regulates your behavior AFTER you leave the employers. This type of restrictive covenant you are talking about covers "outside clinical activities". You are right though that enforcement of these agreements is difficult, and typically requires [threatened] income tax audits, and many times do not happen when these things are discreet.

Generally, inpatient jobs do not have this type of restrictive covenant. Outpatient jobs that are affiliated with government entities also typically do not have this. Outpatient jobs within a faculty practice group typically DO have these, as they do essentially directly compete with cash PPs.

 

[Geodont]

There were several discussions on this topic. Just to be clear, what you are talking about is not a "non-compete", which regulates your behavior AFTER you leave the employers. This type of restrictive covenant you are talking about covers "outside clinical activities". You are right though that enforcement of these agreements is difficult, and typically requires [threatened] income tax audits, and many times do not happen when these things are discreet.

Generally, inpatient jobs do not have this type of restrictive covenant. Outpatient jobs that are affiliated with government entities also typically do not have this. Outpatient jobs within a faculty practice group typically DO have these, as they do essentially directly compete with cash PPs.

Even ER moonlighting in NYC can be subject to limiting future competition. Some go as far as attempting to restrict inclusion of “any” hospital patients in one’s future practice. Endemic to NYC and underscoring efforts to limit competition, is the tendency of various vigorously competing medical centers to extend laterally over a smaller surface area.

 

[hallowmann]

100% true about subjectivity in defining SMI. For those of us long removed from that world, my simple rule of thumb to self is LAI+++ (substance, personality, complex PTSD).
100% a county setting without the added academic institution hyena substrate would have paid more… and maybe even not been so stingy about admin time (well maybe they would be actually, but they’d pay more).
Numerous colleagues that do FQHC work in urban and rural areas told me SMI’s are a smaller fraction of their caseloads.

Yes, it was all tele which does add value. However predominantly SMI tele w/o at least an ACT team (and w/interpretation needs) is not worth 192K at 4 days a week…well 1 or 2 days would allegedly be collaborative care, but in this setting it sounded like adding a ton of PCP drama to the mix rather than casually making recs based on chart review.

Not sure if others consider this a 🚩, but when clinic supervisors/leadership are all very recent graduates (along with enough regular attendings), it gives me the impression they are subsisting on the young and energetic in a labor intensive setting (as most who left were later career folk, but didn’t retire).

What put me off the most is that they refused to define the role clearly (ie “2 days of general outpatient and 2 days of collaborative care consults”). It was like, “Well we’ll see what Dr So-and-So who currently wants to CUT BACK on collaborative care thinks…So have you decided yet?!”
Gimme a break.
Plus it sounded like their federal grant for collaborative care was time-limited or just a pilot program anyway.

…There’s a poster on this thread saying 4 days/wk is the new full time norm now with 1 admin day at such settings, but I don’t find that to be the case in higher cost of living cities.

And heck, I have nothing to hide. This was in NYC with Manhattan academic center affiliation. It used to be a freestanding community health center for decades and it seems various psychiatrists left when the academic affiliation finalized. 🚩
Years ago I stopped practicing in NYC due to the medical-academic-corporate complex becoming unbearable. I would never sell my soul to such a model at fulltime, but if it would give me a base salary while building private practice (in the absence of enforceable no competes), maybe.

Tele FQHC without ACT or case management sounds terrible honestly. The moonlighting I'm doing has great case management, and so I almost never have to worry about things outside of my hours doing med management. It could certainly pay better, but is a CCBHC, is all tele, is the population I'm interested in (dual-diagnosis - which also helps for addiction med practice pathway), and is with people I know and value maintaining a relationship with.

I may be biased with dual training and FM BC, but I'm a fan of collaborative care. The biggest issue is defining roles and boundaries though, which is not something that's easy to do when the program is already up and running or purely run/governed by administration. It really should be run by the psychiatrist with input from primary care based on their specific needs.

NYC and only new grads seems like enough to explain why this is as bad as it is. I thought you were going west coast, so this honestly looked terrible by comparison to the jobs I've seen out there in terms of compensation. You should be paid more. If you are going out West, I would sign up for some per diem work (Kaiser pays ~$200/hr), and then when you're out there it'll be easier to scout 501c3/HRSA jobs. I suspect you'd find ones that are tele out there.

Even ER moonlighting in NYC can be subject to limiting future competition. Some go as far as attempting to restrict inclusion of “any” hospital patients in one’s future practice. Endemic to NYC and underscoring efforts to limit competition, is the tendency of various vigorously competing medical centers to extend laterally over a smaller surface area.

Yeah, these sort of restrictive covenants are simply a non-starter for me. My time after work, should be my time. Anything that restricts my ability to work outside of my working hours is stupid, and even more so in psychiatry where most people seem to have a small private practice. Its one thing that very much turned me off to Kaiser. They told me even if I worked part time in just psych, I couldn't get a job in even a different specialty outside of Kaiser.

 

[Geodont]

I may be biased with dual training and FM BC, but I'm a fan of collaborative care. The biggest issue is defining roles and boundaries though, which is not something that's easy to do when the program is already up and running or purely run/governed by administration. It really should be run by the psychiatrist with input from primary care based on their specific needs.

This. I have a similar background and was drawn by the dangling allure of 1-2 days of chart review in exchange for tele SMI (w/o CM support). When they told me their current collaborative care psychiatrist was trying to cut down on this portion of the work, I started getting cold feet.

In my experience, collaborative care can be a lot of managing frustrating interpersonal dynamics between patients and physicians. That follows w/ unreasonable goals and expectations out of a psychiatric consultation. This is best mitigated, as you note, when psychiatry establishes or manages the initial culture of how things should work. It’s also ideal when more than 1 psychiatrist is involved. I used to get an abundance of PD consults in one specialty setting under the guise of various psychiatric illnesses (and not just because the consulting physicians were clueless).

The other coast is my priority. I got sidetracked with the possibility of what sounded initially like nontoxic 501c tele + CC. Kaiser inpatient gigs can be coveted. They always felt like golden handcuff garbage to me.