Any way for Psych. to make big $$$?

[billypilgrim37]

And people ask why it is important for psychiatrists to learn about psychodynamic psychotherapy?!

Yeah! Because you learn in psychodynamic psychotherapy to only treat people who have plenty of money to afford your services!

I kid, I promise!

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[Bartelby]

If insurance really only pays $50-70/hour for a visit (this is coming from a resident whose parent is in Psychiatry) how do psychiatrists end up making good salaries with reasonable hours?

For example: $50/patient x 8 patients/day x 5 days/week x 52 weeks/ year = $104,000 before tax and any overhead or insurance. That is assuming 8 one hour visits every day and does not even include time for documenting, charting, making calls, whatever other duties are required (or any vacation at all).

I know not all visits will be one hour, but how does a Psychiatrist make in the 100k's after tax if he/she does not have an out of pocket only practice?

 

[Boner]

If insurance really only pays $50-70/hour for a visit (this is coming from a resident whose parent is in Psychiatry) how do psychiatrists end up making good salaries with reasonable hours?

For example: $50/patient x 8 patients/day x 5 days/week x 52 weeks/ year = $104,000 before tax and any overhead or insurance. That is assuming 8 one hour visits every day and does not even include time for documenting, charting, making calls, whatever other duties are required (or any vacation at all).

I know not all visits will be one hour, but how does a Psychiatrist make in the 100k's after tax if he/she does not have an out of pocket only practice?

It's more like reimbursement of $70-80 per med check, doing 4-6 med checks per hour....or at least that's what it was in the clinic where I did my outpt clerkship. New patient visits were along the lines of $250 for an hour of time, but there were only a couple of those a day...maybe.

 

[whopper]

Most of the psychiatrists I know doing the old "give the patient a pill and don't talk to the patient for real" are making more money because they can fit more patients in an hour.

But I'm also noticing that a lot of these doctors don't know what they're doing. IMHO, it's fine to give a patient just a few minutes if all they need is a refill on their meds. If the patient still has problems, the doctor really ought to listen to the patient. In that case, the doctor needs to see the patient for more than 10 minutes.

I've been doing private practice so far for 3 months. Almost all the new patients I have who had previous psychiatrists told me their doctor never really talked to them and they were shocked that I was actually trying to get to know them. Not surprisingly, they're telling me that in just 1-3 months time, they feel better with me than they do with their past doctors. They also tell me they felt better in one month's time with me than with years with other doctors.

As much as that sounds like I'm patting my own back (and I guess I am), IMHO it's really not me having more skill. It's me not wishing to advance the profit at the cost of care. Those other doctors were willing to assembly-line their patients without really getting to know them or their problems.

I've come to realize I will not see 6 patients in one hour unless the patient is completely stable and only needs a refill. The irony there is once I stabilize them, instead of having to see them every few weeks to a month, I'll likely only have to see them every few months--which in effect will spread out those profitable golden gooses thinner...meaning even less money. Aside from that, if you do see 6 patients in one hour, you are likely committing medical fraud because the insurance companies that pay $70 per visit demand a minimum of 20 minutes for that visit. IF you really ramped in to max speed the most you could really be seeing is only 3, and that's assuming you wasted 0 seconds in that hour shuffling the patients.

One of the competing psychiatrists in my county forced patients to see him every two weeks. He never gave them a refill on the prescription, so if they did not refill from him they were screwed. Then he never really talked to them. All he did was write script for 4 or more meds (not kidding). Most of them he put them on 4 meds from day one...usually a benzo, an antidepressant, a mood stabilizer and an antipsychotic all at once. The same guy also gave out lithium and did not order labs.

And you know what? That guy is probably making a lot more than I do.

I figure in time, many of this guy's patients will leave him because that process has already started. A lot of my current patients are telling their friends who see this guy to dump him and go to me.

But as we all know, there are a shortage of psychiatrists out there. This guy got away with what he was doing for years and he was one of the only psychiatrists in the county. I'll probably put a dent in his business but not much of a big dent.

I'm trying to figure out ways to max my profit without compromising the quality. I'm coming up with some ideas, but I don't know if the private practice I work in will be able to accommodate them. E.g. one idea I had was I'll see the patient after the psychotherapist sees the patient. Then the psychotherapist could bring me up to speed--cutting the time I spend talking to the patient while at the same time still addressing the patient's non-biological needs.

I had a non private practice/community service gig in the last academic year that was bringing me big bucks. Maybe I shouldn't have walked away from it, but I had to try my hand in some new scenarios before I figured on settling done in a specific career path. In that gig, I was making just as much as I am in private practice, but I didn't have spend anytime worrying about profit margins. I could spend my focus purely on providing the best treatment.

 

[michaelrack]

Aside from that, if you do see 6 patients in one hour, you are likely committing medical fraud because the insurance companies that pay $70 per visit demand a minimum of 20 minutes for that visit. IF you really ramped in to max speed the most you could really be seeing is only 3, and that's assuming you wasted 0 seconds in that hour shuffling the patients.
.

This probably varies from insurance company to company, but as far as I am aware there is no time requirement for 90862 (pharmacologic management). When I used to do psychiatry, I usually used the standard medical E and M codes (99213 typically)- again with no time requirement- however Mississippi has less mental health carve outs than other states. As far as I am aware, there are only time requirements with the psychotherapy and psychotherapy with medical management codes.

 

[michaelrack]

I'm trying to figure out ways to max my profit without compromising the quality. I'm coming up with some ideas, but I don't know if the private practice I work in will be able to accommodate them. E.g. one idea I had was I'll see the patient after the psychotherapist sees the patient. Then the psychotherapist could bring me up to speed--cutting the time I spend talking to the patient while at the same time still addressing the patient's non-biological needs.
.

Several ways of maximizing profit while maintaining quality:

1. procedures: ECT/sleep
2. clinical trials- though takes several yrs to build up
3. don't take insurance (or bill out of network)
4. Use extenders- such as NP's or psychologists (your idea of seeing the pt after the psychotherapist would be in some ways an example of this, even if the psychotherapist isn't directly in your employ).

 

[whopper]

Mike,

Thanks for the tip on the codes. I'll have to talk about this with the office manager more. I'm their first psychiatrist and I'm new to private practice. We could've been overlooking that.

The extender idea is what happened in the community service gig. 3 months out of that gig and into this one, I realized why the community service gig did it. It makes sense.

I am considering ECT training as well.

 

[HamsterBashful]

Forgive me, I have no experience running a practice, but at $70 a visit, if you see 2.5 patients per hour on average, and you work 8 hours a day on week days, that equates to > $250,000 a year. Would one not consider that to be big $$, at least, if not quite $$$.

 

[whopper]

Yes and no.

Remember, when running a private practice, you likely will have to pay a secretary, pay rent or mortgage on an office, and all other office expenses.

So yes, you will be bringing in > $250K gross, but minus expenses that would be much less.

 

[Manicsleep]

2.5 patients per hour at 70 dollars per patient for 40 hours a week for 50 weeks with 2 weeks vacation is 350K. Take 100k for expenses, some of which will be bills that don't get collected and you have about 250k left over.

Take 4 patients, work 55 hours with a couple of extenders such as psych techs at 65 hours (assuming you dont collect 70 on everyone) for 50 weeks. Now you have a little over 700k. Pay the psych techs and office staff for 300k and you still have 400k. Share the load with another 1 or 2 psychiatrists and you have 450-500k. Work in a multispecialty group where you pay 30k out of your salary to support the PCPs and you drop your salary but you make your life a lot easier. Including call.

So it is quite easy to make more than 250k.

 

[sunlioness]

I've been doing private practice so far for 3 months. Almost all the new patients I have who had previous psychiatrists told me their doctor never really talked to them and they were shocked that I was actually trying to get to know them. Not surprisingly, they're telling me that in just 1-3 months time, they feel better with me than they do with their past doctors. They also tell me they felt better in one month's time with me than with years with other doctors.

This has been my experience as well and many of them are really sad that I am leaving. So they tell me anyway; they could just be being polite. But after a year and change of doing this . . . I haven't really made any money. I'm paying my bills, but my loans are in forebearance, which just isn't sustainable. I don't see any way to practice psychiatry the above way and make the mythical "private practice" salary without working some really insane hours.

This probably varies from insurance company to company, but as far as I am aware there is no time requirement for 90862 (pharmacologic management). When I used to do psychiatry, I usually used the standard medical E and M codes (99213 typically)- again with no time requirement- however Mississippi has less mental health carve outs than other states. As far as I am aware, there are only time requirements with the psychotherapy and psychotherapy with medical management codes.

This is my experience as well. There's no time requirement for a 90862. So conceivably you could see 60 patients an hour for one minute each and bill 60 90862s and not be committing insurance fraud. I bill 90805s, which must be at least 20 minutes long.

 

[HamsterBashful]

In terms of expenses - I know a psychologist who has found a VERY efficient way to run a practice. Specifically, he rents a room from a larger, general practice, which includes only a place for his clients to sit and wait. He then runs all his appointments online or off his cellphone - he just makes sure to respond to every message left on his phone at the end of the day.

Not saying it will work in all circumstances, but hey, he manages to do pretty well for himself!

Another psychiatrist I know went the route of clinical trials - has quite an amazing set up, running between 12 - 15 trials at any given time. He has the help of two nurses, who do physical exams/ecg's/bloods, and manages to see the patients in under 20 minutes (including completion of the mandatory questionnaires etc!). Granted, the patient care might not be optimal, since most of the consultation is spent on paperwork, but the patients seem less inclined to complain when they are getting free meds and consultations. (A bit unethical, I know. I did a survey amongst his patients and wrote a paper about it but my professors banned me from publishing it!).

 

[Manicsleep]

Those clinical trials are on the hitlist for many in the APA/AMA and these people are going to find themselves as not so popular in the future. Look at what happened to relatively reputable researchers like Nemeroff. There are ways being developed to go after these guys who are giving medicine a bad name. I would stay away from this approach unless you are going to do the clinical trial with honesty, integrity and the ultimate goal of advancing patient care.

Remember, once you take on the patient, you are responsible for them whether or not the care is free. If most of the time is being spent on paperwork, proper care cannot be given. The patients can and will sue for substandard care. They arent stupid and know they are being studied. No such thing as a free lunch.

 

[Bartelby]

This has been my experience as well and many of them are really sad that I am leaving. So they tell me anyway; they could just be being polite. But after a year and change of doing this . . . I haven't really made any money. I'm paying my bills, but my loans are in forebearance, which just isn't sustainable. I don't see any way to practice psychiatry the above way and make the mythical "private practice" salary without working some really insane hours.

Statements like the above really worry me as a medical student interested in psychiatry. I don't want to make $250k. I don't need $200k. I could even go a little under the $150k mark. Once I get far below that though it just becomes self-flagellation given my debt load.

So basically does that mean that in order to be a profitable enough psychiatrist I have to specialize or farm out the interesting work (psychotherapy, listening to the patient) to psychologists if I want to see insured or medicaid patients?

 

[Therapist4Chnge]

Many psychologists are farming out the psychotherapy to the mid-level therapists. There is still money to made in psychotherapy, though it isn't through insurance companies.

ps. Not to get too tangential, but there can be good money in running practices, as it can provide a passive income stream. Generating $ and building wealth can be really hard if you are only drawing a salary and/or billing hourly.

 

[michaelrack]

Statements like the above really worry me as a medical student interested in psychiatry. I don't want to make $250k. I don't need $200k. I could even go a little under the $150k mark. Once I get far below that though it just becomes self-flagellation given my debt load.

So basically does that mean that in order to be a profitable enough psychiatrist I have to specialize or farm out the interesting work (psychotherapy, listening to the patient) to psychologists if I want to see insured or medicaid patients?

A psychiatrist (adult) in private practice can't afford to see many medicaid pts, no matter how he practices.

By the way, there are plenty of government psychiatry jobs (state hosp, VA) that pay $150,000. Also comm mental health centers pay that or more.

 

[sunlioness]

So basically does that mean that in order to be a profitable enough psychiatrist I have to specialize or farm out the interesting work (psychotherapy, listening to the patient) to psychologists if I want to see insured or medicaid patients?

No, not listening. You should always listen. But psychotherapy? Maybe. And this is totally a tangent for another thread, but I'm really starting to wonder what the utility of having psychiatrists do psychotherapy is. And by that I mean the 45-50 minute sessions that are devoted strictly to talk therapy and scheduled at frequent intervals.

I don't think our training in psychotherapy is adequate to do the job, to be honest. I think it's important that we be aware of the principles of good psychotherapy and have some experience doing it ourselves just to be able to work effectively in colloboration and effectively function as leaders of an integrated team. And I think residency training provides enough experience in psychotherapy for this purpose. But I don't think we really have the training to be good day-in day-out psychotherapists. Any psychiatrist wanting to practice good psychotherapy is really going to need to take the extra initiative to seek out extra training and extra supervision in psychotherapy specifically that isn't typically provided during residency training.

So why should anyone, private citizen or insurance company, pay a psychiatrist more money than a psychologist or LCSW to likely do something not as well as a psychologist or LCSW would do it? And given how psychiatrists are in critical short supply for things that no one has superior training for than we do, should we really be doing it anyway?

I don't know. Not trying to start something here, but just something I've been kicking around more recently. [And something I would have been very upset to hear and would have argued against vociferously a few short years ago.]

 

[TheWowEffect]

No, not listening. You should always listen. But psychotherapy? Maybe. And this is totally a tangent for another thread, but I'm really starting to wonder what the utility of having psychiatrists do psychotherapy is. And by that I mean the 45-50 minute sessions that are devoted strictly to talk therapy and scheduled at frequent intervals.

I don't think our training in psychotherapy is adequate to do the job, to be honest. I think it's important that we be aware of the principles of good psychotherapy and have some experience doing it ourselves just to be able to work effectively in colloboration and effectively function as leaders of an integrated team. And I think residency training provides enough experience in psychotherapy for this purpose. But I don't think we really have the training to be good day-in day-out psychotherapists. Any psychiatrist wanting to practice good psychotherapy is really going to need to take the extra initiative to seek out extra training and extra supervision in psychotherapy specifically that isn't typically provided during residency training.

So why should anyone, private citizen or insurance company, pay a psychiatrist more money than a psychologist or LCSW to likely do something not as well as a psychologist or LCSW would do it? And given how psychiatrists are in critical short supply for things that no one has superior training for than we do, should we really be doing it anyway?

I don't know. Not trying to start something here, but just something I've been kicking around more recently. [And something I would have been very upset to hear and would have argued against vociferously a few short years ago.]

Better late than never...

This is something I realized back in residency itself. Optimal use of available resources is very important. Of course, we should utilize the psychotherapy skills even when we do med management/90862s and of course, when doing the timed 20 minute (90805) when warranted. I usually will see the patients for 90805 for first few visits and then switch to 90862.

To others in this thread- Don't worry about making money. You'll be able to make more than enough and also love doing it.

 

[loveoforganic]

Several ways of maximizing profit while maintaining quality:

1. procedures: ECT/sleep
2. clinical trials- though takes several yrs to build up
3. don't take insurance (or bill out of network)
4. Use extenders- such as NP's or psychologists (your idea of seeing the pt after the psychotherapist would be in some ways an example of this, even if the psychotherapist isn't directly in your employ).

How is this? Grant money?

 

[Manicsleep]

I don't think our training in psychotherapy is adequate to do the job, to be honest. I think it's important that we be aware of the principles of good psychotherapy and have some experience doing it ourselves just to be able to work effectively in colloboration and effectively function as leaders of an integrated team. And I think residency training provides enough experience in psychotherapy for this purpose. But I don't think we really have the training to be good day-in day-out psychotherapists. Any psychiatrist wanting to practice good psychotherapy is really going to need to take the extra initiative to seek out extra training and extra supervision in psychotherapy specifically that isn't typically provided during residency training.

So why should anyone, private citizen or insurance company, pay a psychiatrist more money than a psychologist or LCSW to likely do something not as well as a psychologist or LCSW would do it? And given how psychiatrists are in critical short supply for things that no one has superior training for than we do, should we really be doing it anyway?

No offense, but I think a competent shrink should have learned to do psychotherapy as well or better than any other therapist. That they fall out of practice is another thing but they should be able to supervise the process and know enough about it always.

Regarding paying more, I think the psychologists will give you an excellent answer as they have no intention of getting paid like an LCSW, much less like a psych tech. I wish I could have my psych techs bill like psychologists because they are as good or better than the average psychologist in providing individual and group therapy.

 

[sunlioness]

No offense taken, Manicsleep. I appreciate your viewpoint. I guess I just don't understand how we can expect to be better psychotherapists than the therapists. I mean this was my psychotherapy training, which I think is fairly typical.

Throughout residency, we had didactic classes on various types of psychotherapy. We had a class on CBT, a class on supportive, a class on psychodynamic, a class on marriage/family and a class on group. These classes were conducted over the first two years of residency and did not directly involve any sort of practical supervised direct clinical experience doing psychotherapy. During our IOP rotation as PGY-2s, we were occasionally asked to run group therapy sessions. Though most days the psychology interns did this, while we focused on medication management.

During our outpatient year, we were required to select a certain number of patients from our clinic population to be therapy cases. We had to demonstrate competency in supportive psychotherapy, CBT, psychodynamic and combined psychotherapy/psychopharm. During this year we met individually with a therapy supervisor (a psychologist) for one hour per week to go over cases and collectively as a group with another faculty psychologist for one hour a week to go over cases together. With some exceptions, we were not observed doing psychotherapy. Competency was demonstrated by writing a case report for each of the required modalities that our individual supervisor then signed off on. That was all that was required. Now they were other opportunities available for people who were particularly interested. A local university had residents come in to do brief psychodynamic psychotherapy with their students and residents who participated in that program had an additional supervisor over there. There was also a program that provided free psychodynamic psychotherapy to low income folks and that program (which I did participate in) came with another supervisor with whom you met for one hour per month. There was also a resident in my class who on her own initiative designed an intensive psychotherapy experience and this was supported by my program. But this is still all peanuts compared to the training most other people who do therapy get in graduate school and what psychologists get during their internship. Not to mention that those folks are required to have a significant number of supervised clinical hours after graduation before they are even allowed to be licensed independently. I just don't understand how exactly I am expected to be a better psychotherapist than they are. It seems as messed up to me to assert that this is the case as it would be for a psychologist to assert that s/he can prescribe meds as well as I can because s/he took an RxP course.

I definitely agree that we need to know enough about psychotherapy to understand what it is psychotherapists are doing and to be able to assess whether they're performing it competently. I agree that psychotherapeutic skill is necessary for any "med check". And I think residency training is adequate to the task of preparing us to do this. But not to be day in/day out psychotherapists. And I don't think doing so is an effective use of our time and training either.

Anyway, sorry if this is a thread derailment. If a mod wants to create a new topic out of this, please feel free to do so.

 

[whopper]

This has been my experience as well and many of them are really sad that I am leaving. So they tell me anyway; they could just be being polite. But after a year and change of doing this . . . I haven't really made any money.

If you're doing what I'm doing, it's likely more than just being polite. My scores at one year in a state job and one year in a community service gig were the highest off all attendings working at the place--for years.

I don't claim to be some type of genius, House-type of doctor. I do claim though to at least try to follow the standard of care, do a good job, and listen to my patients.

I've noticed in several residencies, the attendings expect their residents to do top-notch work, but the attendings themselves aren't doing it. Medical students and residents are eager to please and hardworking. Those two factors could blind them to the fact that the attending may in fact be a poor doctor. In several programs, I've heard attendings mention something to the effect of "I only took this job because I could have residents doing my work for me."

If my perception is correct based on what I see from colleagues, what I'm doing is above the norm, and they are actually doing what is considered less than the standard of care. Giving a patient lithium without even doing an interview, not ordering labs, and basing the diagnosis on the PCP's referral "I think he has bipolar" appears to be quite common. That's not just where I'm at, it's been everywhere I've practiced. The only times I've felt surrounded by psychiatrists where this was not the norm was in fellowship (and my PD was ranked one of the top 100 doctors in the country) or when I was sitting at a state branch APA meeting. Most of those doctors were top-notch.

(Off on the side, an interesting mental puzzle. If the majority of people do work that is below the standard, then that is by defintion supposed to be the new standard. The standard of care is supposed to be geographically based. So if 60% of doctors in the area doing private practice are not interviewing patients and just giving them meds--is that the new standard of care?)

Just from my anectdotal experience, at any hospital I've worked in, about 50% of the doctors were clueless to the point where I would not want them treating my friends for family.

I've noticed several people on this board actually care about psychiatry. Others go into a profession simply because it makes money or they didn't know what else to do. (E.g. during MATCH application time they don't know what field to pick.) Anyone with a passion for what they're doing usually at least do a decent job. Usually they do a great job.

As for me, I'm not yet hitting the big mega-bucks with private practice. I'm tallying it up to 3 factors.

1) I still haven't been approved by 2 major insurance companies. I have a floodgate of patients wanting to see me but can't until I'm approved.
2) Due to the above, my 16 hrs/week hours set aside for private practice are not yet filled up. So far I'm averaging only about 8 hrs a week.

3) Most of the patients I'm seeing, I 'm still seeing for the first time. I'm still in the zone where I can't just refill their meds yet. I figure I will get there in a few months.

I am also starting suboxone treatment that is out of pocket. That should also rake in some money.

I'm going to give this at least 6 months, maybe a year before I tell my boss something to the effect of "I can be making a lot more doing community practice, and community practice is less work."

 

[whopper]

No offense, but I think a competent shrink should have learned to do psychotherapy as well or better than any other therapist.

Psychotherapy training is highly variable depending on the program. Some programs have a very in-depth biological approach. I've noticed several attendings even looking at psychotherapy with disdain. If a program is to the point where a sizeable number of psychiatrists are of that opinion, it could greatly and adversely impact the psychotherapy curriculum.

IMHO psychiatrists are likely to not get psychotherapy as well as the other professions. This will likely be the case even in a psychiatry program where everyone is committed to pushing a good psychotherapy curriculum.

The clinical reality is that residencies are paid for by the government, and residents make the program money by providing cheap labor that would've otherwise been provided by an attending. For that reason alone, residents will likely only have experience with brief supportive therapy. As we all know, that is only the tip of the iceberg (I'd describe is as more like a grain of salt in an ocean) in context of the enormity of what could be learned and experienced in psychotherapy.

I've mentioned this before. Borderline PD is a major problem encountered by psychiatrists, and we often get those patients because of the severity of the case (e.g. cutting wrists, suicidal threats, etc.) Yet I don't know one, not one psychiatrist who is skilled in DBT. Out of all the psychiatrists I know, I'm the most skilled and that's because on my own, I've read books on it and my wife is skilled in that area. I'm learning a lot from my conversations with her over my frustrations with borderline patients.

The above is not a defense for the lack of psychotherapy training, it's a strong criticism of it. My wife received her master's in counseling, and is working on her Ph.D. Her psychotherapy training is to a degree that I've never seen any psychiatric program come close to in terms of depth, hours for psychotherapy, and what is taught in class.

IMHO, a psychiatry residency should be the equivalent of a bachelor's degree in terms of credit hours spent in lecture and having tests in addition to the clinical work. The reality is most of it is just work in the field, our behavioral sciences training before residency was paltry, and when we do have classes, we are not tested and often suffering from lack of sleep from the call last night. For PGY 1s and 2s, their focus is not on psychiatry, it's on passing the USMLE Step III, of which, as we know, only 10% of that exam is psychiatry. For that reason, very few psychiatry residents really pay attention during lectures. Instead of lectures being the equivalent of a bachelor's, it's more like 25% of that. We do learn plenty of clinical information--from experience on the field.

Attendings seem to further support the above. If a patient is rowdy on the unit, the attendings often care much more about that immediate need, and the resident's response to it much more than the resident's paying attention in a lecture vs. other residents being half awake due to the call the previous night. I recall several lectures where students were openly studying internal medicine during a psychiatry lecture--becuase their USMLE exam was coming up.

From my anectdotal experience, it seems to me that the psychiatrists that are good in psychotherapy are the ones that on their own, read up on it and sought post-residency training in it. Either that or they're just people that are easy to relate to--which is not too many M.D.s from what I've seen.

 

[Manicsleep]

I did DBT for 3 years in residency as did 4 others in my class. Everyone did it for at least one year. Also, there are plenty of therapists who don't even understand the concepts behind DBT.

Are there some poor programs that are mostly supportive therapy oriented with only theoretical training in psychotherapy? Yes. However, therapy is done at bedside as well and also by the therapists that are in these training programs. It is a requirement of ACGME accreditation.

So if you go to a program that is bio heavy and want more therapy, it is up to you. Nonetheless, be prepared to know it no matter what. You will be tested on it on your written and oral boards. I know I would fail anyone who didn't know their psychotherapy on an oral board exam...and I am going to be an examiner soon.

 

[sunlioness]

Agreed, but part of what I am trying to say is that there is a difference between book knowledge and practical/experiential knowledge. And being able to pass a written or an oral exam (which I have done) does not immediately translate into actually being able to do the work with any degree of competence.

To use Whopper's example, I know that DBT is the empirically validated treatment of choice for BPD. I could easily pick that out of a multiple choice. Furthermore I know that DBT was developed out of CBT by Marcia Linehan. I know the basic principles of DBT and could likely talk about it in enough detail to impress a board examiner. Throw me in a room with a borderline and tell me to do DBT? I'm not going to be very good at it because I've never actually done it before. I could get good at it over time with the appropriate experiences, supervision and mentorship, but part of the point I was making is that my training didn't provide me with such and as a general rule I don't believe that psychiatrists' training in psychotherapy is equivalent to what psychologists receive. Of course there will always be your individual psychiatrist who went the extra mile and your individual psychologist who skated through and didn't learn anything. But those aren't the rule.

 

[whopper]

I did DBT for 3 years in residency as did 4 others in my class. Everyone did it for at least one year. Also, there are plenty of therapists who don't even understand the concepts behind DBT.

That is very good. So I can now say I know of one psychiatrist out of dozens that knows DBT, yet all of those dozens are treating borderline patients using psychotropics and without referring them to someone that can do DBT, and psychotropics aren't the recommended treatment for borderline PD, DBT is.

However, therapy is done at bedside as well and also by the therapists that are in these training programs. It is a requirement of ACGME accreditation

Furthering what Nancy wrote...

There's a difference between someone that actually learned how to do CBT, or a better example--DBT for real. You can't do DBT unless you learned the material in the books such as mindfulness, radical acceptance, etc....

VS. someone that was just told "DBT is the treatmnet for borderline PD." Without being given academic and clinical instruction on how to utilize it.

However, therapy is done at bedside

There's a difference between someone who is by the bedside of a borderline and trying to give emotional support vs. someone that actually knows the theory of how DBT is supposed to work, studied that theory, and has someone overseeing that therapy. If you know DBT, then you also know you just can't stick someone a resident by the bedside or a borderline patient and expect them to know it.

All programs stick a resident with a patient and expect them to do psychotherapy out of a hat. All of them do that--even the good ones. At least in the good ones, after several months, in addition to the above, the resident will eventually get instruction to the point where they're no longer pulling it out of a hat, but many still do not give formal instruction on the specific psychotherapies.

In addition to the DBT example I gave above, very few psychiatrists know how to really do CBT. If I asked most of my psychiatric colleagues what a triple column technique was, I'd bet only a small minority would know.

but part of the point I was making is that my training didn't provide me with such and as a general rule I don't believe that psychiatrists' training in psychotherapy is equivalent to what psychologists receive.

Unfortunately, from what my psychologist colleagues are telling me, their profession too is having some of the same problems ours is. The focus in psychology is academics and statistical analysis, then trying to apply behavior to statistics. Their clinical training can have a lot of the same weaknesses psychiatrists do. E.g. they could have a statistical-heavy curriculum with very little direction in psychotherapy--while we have a clinical heavy curriculum with possible poor direction in psychotherapy.

I have only seen one counseling program's curriculum, and that had very good psychotherapy direction with very in depth training. (Remember counseling is a different major than psychology).

Also, there are plenty of therapists who don't even understand the concepts behind DBT.

True, but the definition of a psychotherapist is broad. A social worker could be considered a psychotherapist and they have no psychotherapy training.

IMHO, our psychotherapy training should at least meet the expectations of what we're supposed to do on the field. If we're supposed to treat borderlines, then we should know DBT or refer them out. That is not the case with what I'm seeing in several geographical areas including Philadelphia, NYC, north NJ, and south NJ (NYC being a psychiatric mecca and still it's not happening). No DBT training, and psychiatrists continually as a whole treat borderline with psychotropics only to see no improvement, but the problem continues.

Ironically in Ohio, I'm seeing the DBT utilization and I still don't think it's what I'd like it to be. Several state mental health boards are directing their members to have at least a few trained in DBT and are implementing DBT programs and 24-hr DBT therapists to prevent the cycle where borderlines get rehospitalized over and over.

 

[Manicsleep]

I agree that theoretical concepts need to be taught and the ACGME is supposed to be checking up on this. Part of the responsibility lies with residents as well to speak up if their instruction is subpar. We expect to be treated like adults but act like infants at the nipple. I have said this to residents many times: if you are going to say and claim that you are an MD (or DO) then act like one and stand up for yourself. However, there are many, many training programs with excellent psychotherapy training. Especially on the coasts but also in the south, texas and the midwest.

I also agree that many psychologists have awful psychotherapy skills. This is why I disagree with the notion that they are any better than psychiatrists. Some of the graduates of the PsyD schools are just terrible even though they are licensed.

There is a push to say that psychologists are somehow better trained and this is pure fallacy. There is a spectrum in both fields and I think the spectrum is much tighter in psychiatry. These "master plans" such as those recently unveiled in SD this year by psychologists are all part of this push for greater scope of practice. This is being done by inflating psychologists abilities and minimizing the training of psychiatrists. Unfortunately, there are too many in our field who are willing to give ground because they fear failure and loss of perceived respect/admiration. The worst part is that some are even buying into this propaganda without adequate research due to the "it must be true because I saw it on TV" effect.

 

[sunlioness]

Part of the responsibility lies with residents as well to speak up if their instruction is subpar.

I think part of the problem is that residents don't necessarily know that it is. I know when I graduated residency that I honestly felt that I was ready and had the necessary experience to be a good psychotherapist. No one ever told me otherwise and I didn't have any other model of training at the time with which to compare my own. So I don't know that expecting residents to recognize where their curriculim is deficient is necessarily reasonable. It's really only since being out on my own and actually doing psychotherapy routinely and comparing my experiences with other therapists I work with that I've started to have these thoughts.

These "master plans" such as those recently unveiled in SD this year by psychologists are all part of this push for greater scope of practice. This is being done by inflating psychologists abilities and minimizing the training of psychiatrists.

They may be trying to do this, but I don't think it holds in any water. Saying "psychologists have superior training in psychotherapy and this means they should be allowed to prescribe medications" is just plain ridiculous. It's just as ridiculous to somehow assert that psychologists offer superior care overall just because their training model provided them with more psychotherapeutic experience. I think each field has its strengths and patients do better when we work collaboratively with each team member doing what it is they are best trained to do.

Overall I think my clinical training in residency was pretty darned good. I think it made me into a competent psychiatrist who does a good job. But it didn't make me an excellent psychotherapist. And I wonder if that should even really be a goal of residency training? Do psychiatrists really need to themselves be good psychotherapists? Or is it enough to have a working theoretical knowledge with enough skills to be appropriately supportive and empathic in the course of providing treatment, make appropriate referrals, and keep tabs on the psychotherapy experience the patient is having with a different provider? Is it cost effective for society to be paying psychiatrists to do routine psychotherapy?

These are the things I wonder. And a good part of this is spurred by the fact of how gung ho I was about being a therapist in residency. I really thought I loved it and was going to be great at it and wanted to devote a large bulk of my practice toward seeing therapy patients. As time went on, I realized not only am I not as good at it as I thought I was, I don't actually like it as much as I thought I would either. So take everything I am saying with that grain of salt.

Thanks for the cool discussion, guys.

Edited: As for the point that psychology training isn't so great for psychotherapy either because they are focused on statistical analysis and such things or that social work training in psychotherapy isn't so great because they focus on working with systems or any other such argument . . . You may very well be right about that. I've definitely worked with my share of psychotherapists from these fields who I didn't think were that great.

 

[whopper]

Apologize--I referred to Sunlioness as Nancy.

Manicsleep: sorry for any unintended sarcasm. When I read my previous post and wrote something to the effect of -Now I know 1 psychiatrist that gives DBT, in hindsight that comment sounds very sarcastic and snarky. I meant that it is good that you know how to do DBT, wish more learned it, but still, one out of dozens, possibly hundreds of psychiatrists I've met is still too low.

And I apologize for steering this profit thread off course! Maybe we should start a new thread?

But to add what will hopefully be my last on this topic, I've seen plenty in my wife's counseling curriculum who are also poor psychotherapists despite the curriculm being good. Those people simply did not care and chose the major because they didn't know what to do after they graduated college and/or they didn't have enough requirements for a psychology major.

To be a good psychotherapist, you have to care, have good experience, and have studied to some degree the psychotherapy techniques. IMHO, even if a program offered good training, after 4 years, it's only going to be the beginning of what you need to learn. For those that have a disdain for psychotherapy, the door to learning and enhancing psychotherapy skills will not advance until the attitude changes.

Simply because one is a psychiatrist or psychologist is unlikely going to have much bearing on their skills as a psychotherapist. Like I said, plenty of psychologists I know focused almost completely on statistics. Their own curriculums were not focused on psychotherapy but rather a curriculum that would push out published articles.

IMHO, in general, for that reason I do believe that psychologists as a whole (not as individuals) may be better in applying statistical principles to the behavioral sciences vs. psychiatrists. However, as psychotherapists, are they better as a whole? No way.

The first person that turned me onto what I believe is real clinical psychotherapy was a professor of mine in college (Atwood-Rutgers). He told me how he spent years doing statistical analysis as a Ph.D. student in psychology and had minimal clinical experience. (I think he actually said he had none and got his Ph.D. The memory is years old and he is not a young man. Maybe that's the way the curriculums were decades ago?) He became a clinical psychologist and his first patient was someone who sat in a chair, stared at him and only said "hit me.....hit me.....hit me" on and on, each session, 1 hour a day whenever he saw her and it continued for several months.

He told the class nothing in his academic training prepared him for that.

 

[erg923]

The Scientist-Practitioner model of doctoral training in clinical psychology (AKA: the Boulder model) has been the primary training paradigm for the Ph.D. degree in clinical psych since 1948. In brief summary, the model subscribes that a psychologist is a scientist and a competent researcher, and also a practitioner who applies knowledge and techniques to solve problems of clients.

There has been a long running gag that the model produces good scientists and poor practitioners. Some personality psychologists have gone so far to say that the characteristics/traits that make a person a productive researcher are the same ones that make a poor therapist. However, the popular stereotype of the nerdy researcher with poor people skills is much overblown I think, and as as I recall, there is some good empirical research about this stereotype by a social psychologist, maybe at Iowa? Ill have too look it up. Anyway, while this can be true of course, the point is that the scientist-practitioner model has produced many astounding researchers and clinicians over the years. Many of the people I'm talking about made careers in both roles...with incredible skill and knowledge i might add. Rogers, Meehl, Hathaway, Ellis, Alport, Strupp, Prigatano, Rotter, Reitan, Kaplan, the list goes on. Moreover, in my training I have only encountered one person (out of dozens and dozens) where their scientific mindset truly got in the way of being a good therapist. The point I'm trying to make is that I do not think our training in statistical procedures and research methodology interferes with our training as clinicians at any significant rate. When its does, I really think this is the individuals personalty/preferences coming out, rather than a failure of the training model per se.

Unfortunately, it has often been interepreted that since the "scientist" part comes first in the term, that it denotes this as primary (i.e., "you are a scientist first and a practitioner second"). This is also an inaccurate myth and is often reinforced by psychologist themselves. Its not a split model. It suppose to be one informing the other. Do my clinical experiences influence my research questions and hypothesis? OF COURSE! Does a skeptical, scientific mindset help me wade through all the garbage treatments/interventions and junk science out there in order to select the best treatments for my patients? OF COURSE! Does my experimental knowledge learning theory, "rat running" literature, and reinforcement contingencies inform my therapy models? OF COURSE! Does knowledge of statistics help clinical decision making? OF COURSE! (so many people do not take into account base rates when making clinical or diagnostic decisions).

 

[erg923]

The first person that turned me onto what I believe is real clinical psychotherapy was a professor of mine in college (Atwood-Rutgers). He told me how he spent years doing statistical analysis as a Ph.D. student in psychology and had minimal clinical experience. (I think he actually said he had none and got his Ph.D. The memory is years old and he is not a young man. Maybe that's the way the curriculums were decades ago?) He became a clinical psychologist and his first patient was someone who sat in a chair, stared at him and only said "hit me.....hit me.....hit me" on and on, each session, 1 hour a day whenever he saw her and it continued for several months.

He told the class nothing in his academic training prepared him for that.

Yes, that is very much true, but it did vary widely by program . In general however, up until 1970 or so, the typical timeline in a clinical psych Ph.d program was: 2 years of hard psychological science-learning theory, stats and methodology, and general theories and principles of human behavior (both normal and abnormal). During second year you would prob have one course in assessment and one in therapy and a maybe a small practicum doing one or both of these. 3rd year was internship-where you finally got to apply all the science you learned. Many in the 50s and 60s had little (and sometimes zero) clinical experience before this internship year. During 4th year it was back to university to complete the dissertation. It was very, very academic, despite the fact that most Ph.D's still went into practice. I think there was alot of "learning on the job" back then.

Fortunately, things no longer operate this way and the vast, vast majority of clinical ph.d. programs offer ample opportunities to become a well rounded clinician in addition to your scientific training. Thus, I do not think blaming your ph.d program for your a lack of psychotherapy skills/training is very viable today....

 

[whopper]

Unfortunately, it has often been interepreted that since the "scientist" part comes first in the term, that it denotes this as primary (i.e., "you are a scientist first and a practitioner second"). This is also an inaccurate myth and is often reinforced by psychologist themselves. Its not a split model. It suppose to be one informing the other. Do my clinical experiences influence my research questions and hypothesis? OF COURSE!

Sounds like a lot of the parallels in psychiatry residency. Several see some components as separate or inferior to others. Thanks for clarifying some of what my psychology colleagues are telling me.

 

[Majesty]

There is a push to say that psychologists are somehow better trained and this is pure fallacy. There is a spectrum in both fields and I think the spectrum is much tighter in psychiatry. These "master plans" such as those recently unveiled in SD this year by psychologists are all part of this push for greater scope of practice. This is being done by inflating psychologists abilities and minimizing the training of psychiatrists. Unfortunately, there are too many in our field who are willing to give ground because they fear failure and loss of perceived respect/admiration. The worst part is that some are even buying into this propaganda without adequate research due to the "it must be true because I saw it on TV" effect.

I went to a mid tier program with a bio focus. But I learned psychodynamic therapy and CBT (and of course supportive). I don't do therapy now at all but I do run treatment teams where I talk about goals of treatment with LCSWs and psychologists. None of these people, there are graduates from IVY league schools here, know any more than me with respect to therapy.

The Scientist-Practitioner model of doctoral training in clinical psychology (AKA: the Boulder model) has been the primary training paradigm for the Ph.D. degree in clinical psych since 1948. In brief summary, the model subscribes that a psychologist is a scientist and a competent researcher, and also a practitioner who applies knowledge and techniques to solve problems of clients.

This applies to a very very small number of psychologists, although most recently graduated PhDs from top academic university programs do meet this criteria.

It is interesting how psychologists differentiate themselves from psychiatrists as if they are scientists and we arent. All physicians learn stats and some excel in the field. A vast number are proficient although a few have forgotten which is a shame. I would say the percentages are better for psychiatrists than psychologists however.
Also, statistics make you able to understand the hard data, they don't make you a scientist or proficient in science. There is more than that. To use that would be a very narrow definition of the word. You can get a bachelors in science without knowing a lick of statistics.

Medicine is a science. Psychiatrists are scientists. Most psychologists are not. Scientist-Practioner propaganda is...well I will just quote what has already been said.

inflating psychologists abilities and minimizing the training of psychiatrists

 

[erg923]

Don't pound your chest too hard there pal, I wasn't pounding mine.

I was simply explaining that I don't feel the academic and experimental training of a ph.d degree means that one will come out undertrained in psychotherapy and/or approach psychotherapy from a narrow viewpoint. When that happens, its probably due to the person (e.g., personality, biases), not the training model.

 

[Majesty]

Its interesting that you see the idea that psychiatrists are scientists and practitioners as well as therapsists and physicians to be chest pounding.

You were positing a theory and I was discussing a theme with other psychiatrists here. Only a small part of that had to do with your post. If your feelings got hurt, too bad.

 

[erg923]

Message board posts do not hurt my feelings, but glad to know you're empathetic...

 

[Majesty]

Back to the intended point of this thread.
I think it is possible to make more than 250k or close to that. However, it is much easier to do it with a subspecialty like child, pain, addiction, sleep or geriatrics.

I do outpatient part time and successfully but for me its very stressful. I wish I had a few others to take call. I havent had a real vacation in 2 years. The money holds me to the job.
I have tried to go full time outpatient but theres just not enough cash patients. So I do contract work to make up the money. There is plenty of that, sometimes I have to go places I don't want to.

Insurance doesn't pay enough for 1 person. I have a friend who is a PGY4 in the area and will be joining me in July 2011. Then we can share call, rent, secretary, billing etc.

 

[whopper]

Many psychiatrists I know are not scientists or anything close. I'm talking about the psychiatrists that don't follow the guidelines and have no evidenced based data to back their decisions.

E.g. Neurontin for bipolar disorder. If I had a dime for every time I've seen a patient given Neurontin for bipolar disorder.....

Many psychologists I know I would consider scientists.

There's good and bad in every field.

 

[erg923]

I agree with you Whooper, however, majesty does have a point in that, unfortunately, many Ph.D. trained psychologists do not live up to that standard either (even though most are indeed trained in the scientist-practitioner model). EMDR proponets (which is effacious, but its NOT due to the eye movments people), rebirthing therapy, etc. are rampant in the psychological community despite their weak empirical support. Continued use of the Rorschach (especially in forensic cases) fits into this category as well, and IMHO, is a embarrassment to scientific clinical psychology.

This is part of why Richard Mcfall and others have pushed so hard for the "clinical science" model of doctoral training, where producing clinical psychologists who function as clinical researchers is the primary goal. While their commitment to rigorous training in science/research is admirable, I cant help but see through their not so subtle disdain for the practitioner part. Under this model, I fear my profession would be pumping out pure academics with minimal therapy skills who indeed would (should) be scoffed at by many psychiatrists in the clinical trenches.

 

[billypilgrim37]

EMDR proponets (which is effacious, but its NOT due to the eye movments people)

One weekend on consult call, one of the social workers, who generally mistook me for a carpenter who could build beds in which to put her patients, asked me out of the blue what I thought about EMDR. She had apparently just done one of the trainings (for which she, of course, paid some serious cash). I laughed and said, "Of course EMDR works. It's CBT with magic sprinkles on top!" and I swear she crapped herself with rage at me. I'm still proud of this line.

 

[sunlioness]

*giggle* That's awesome. Personally, I think the real point of EMDR is nothing more than focused mindfulness, throw in some CBT and some eye movement "sprinkles" and yeah, it kinda works. And yeah, what they charge to get trained in it is nothing short of highway robbery.

 

[Manicsleep]

Want to make 250k.
Make up some crackpot scheme, like left nostril breathing therapy or something, apply CBT principles and say its new. Use it for the latest thing in the news.

Then sell it!

LNBT is mine.

 

[Manicsleep]

Whopper, you wouldn't by any chance work for or get most of your referrals from psychologists would you?

 

[whopper]

I do.

I mentioned in the Child Psychiatry Thread is miserable that I entered private practice in an office owned by a psychologist and I'm the only psychiatrist there.

If you asked because of my occasional defense of psychologists, I occasionally notice possible group-think on our parts against psychologists. The psychologist prescription thread is an example.

I have a bachelor's in psychology and I learned thing relevant in treating others from that major that I did not learn in psychiatry residency, nor do I see these things taught or emphasized in residencies in general.

Getting back to the money factor, one needs to also factor in benefits and the retirement package.

Several government jobs offer great retirement packages and you can rest assured that the government will still be in existence to give you your retirement money by the time you retire (otherwise you ought to buy a shotgun, non-perishable food and perhaps a fortress like bomb shelter to live the rest of your days).

Many of those jobs also will pay off your loans much better than a private gig.

My current state job is interfacing well with my private gig because whenever a patient calls the private practice, the practice calls me up and tells me what's going on. At my state job, out of the 32 hours a week, 16-26 of those hours, I usually got nothing to do. I've been literally doing yoga, watching movies, reading books (for entertainment) during my state job, and my state job performance numbers are some of the highest there. Since it's a forensic facility, I can't discharge my patients after they've been stabilized,--a judge has to do it. I've written the judges on all my patients that they are stable and we don't hear back from the judge for weeks to months.

So I got a unit full of stable people and I can't do anything else. They're happy on their meds. In many of those cases I've gone above the typical "stabilize them" mindset. I've tried multiple regimens (only at the patient's request) to see if a specific medication worked better for them vs. another even after stabilized so they could get the medication they were most happy with. I got not much to do to the point where I'm actually wondering if all this free time is good for me.

What I'm liking about this current set up is that I still get the benefits, but I also can make more money in private practice. The private practice gig is not yet earning what I anticipated but I think it'll get there in a few months.

 

[Manicsleep]

I think you generalize quite a bit Whopper. Talk to some of the psychiatrists who have worked all over the country in non academic and academic settings. You will notice that the quality of psychologists varies immensely. Especially of late but this is no new phenomenon.

Whether you being employed by psychologists as well as easily identifiable has anything to do with your stated views cannot be said for certain.
Whether it has to do with your major is unlikely. I majored in psychology as well although I had another major.

That you don't see these things taught in residency and see them in other places is normal for someone fresh out of training. They are used to the good in their profession and take it for granted. They see different approaches and think they may be better because they are able to incorporate them and improve their own practice. Wait a little bit, you will see that you can do anything a psychologist can do, from testing to therapy to research (although you may have to work at it, you have the tools). While they will not able to be a physician...ever. No matter how many online classes they take and even if they prescribe.

To the financial aspect.
State jobs are good and fine but they drive me nuts. Private practice is where its at. I can work as much as I want or as little although I rarely work less than 50 hours a week and have put in 80 or more (another reason that the government work would drive me crazy).

This applies to private practice as well. Initially you really have to toil. I mean really really hard. The patients, the PCPs and other psychiatrists/therapists must trust your word and realize that you are dependable, trustworthy and competent. I am finally getting the rewards of that now.
Can't wait to try concierge with round 2.

 

[Majesty]

Private practice is cool b.c. ur the boss (if your the boss, otherwise I would never do it). The stress is unreal when you are on call 24/7/365. I have worked a lot of 80 hour weeks in the past year.

 

[edieb]

Can I see data supporting your assertion that an psychiatrists can do research, testing and therapy as well as psychologists? I need data. I must have it.

I think you generalize quite a bit Whopper. Talk to some of the psychiatrists who have worked all over the country in non academic and academic settings. You will notice that the quality of psychologists varies immensely. Especially of late but this is no new phenomenon.

Whether you being employed by psychologists as well as easily identifiable has anything to do with your stated views cannot be said for certain.
Whether it has to do with your major is unlikely. I majored in psychology as well although I had another major.

That you don't see these things taught in residency and see them in other places is normal for someone fresh out of training. They are used to the good in their profession and take it for granted. They see different approaches and think they may be better because they are able to incorporate them and improve their own practice. Wait a little bit, you will see that you can do anything a psychologist can do, from testing to therapy to research (although you may have to work at it, you have the tools). While they will not able to be a physician...ever. No matter how many online classes they take and even if they prescribe.

To the financial aspect.
State jobs are good and fine but they drive me nuts. Private practice is where its at. I can work as much as I want or as little although I rarely work less than 50 hours a week and have put in 80 or more (another reason that the government work would drive me crazy).

This applies to private practice as well. Initially you really have to toil. I mean really really hard. The patients, the PCPs and other psychiatrists/therapists must trust your word and realize that you are dependable, trustworthy and competent. I am finally getting the rewards of that now.
Can't wait to try concierge with round 2.

 

[Ollie123]

I would totally agree that the variability in psychologists training is quite large. However, I'm going to have to disagree that it is any better for psychiatrists...there is no shortage of crappy psychiatrists out there too (yes, even board-certified) and we get referrals to our clinic all the time where people have been in the system for years and never once seen a competent clinician of any form, regardless of degree. Really though, this is just a matter of perspective. Whopper has had good experiences with psychologists, you apparently have not. I have some bad experiences working with psychiatrists, and some excellent experiences working with them. I'm not convinced anyone is right and frankly, I think its irrelevant. I'm the first to acknowledge the huge variability in psychology training, though I actually think the lack of research training is a bigger problem than the lack of clinical training right now. While there are certainly exceptions, I think the research-heavy programs are actually producing people who will make far better clinicians in the long-run (maybe not straight out as they may not have as much experience, but I think the research-focused programs do a better job of long-term preparation and teaching people to be self-learners rather than the "Mental mechanic" type training of many of the programs out there) than many of the programs that are professing to stress clinical skills...though the reality is that even at a VERY research-intensive program I will get as much or more clinical experience than many of those students. Mine will also strictly be in things that have been proven to work, which is unfortunately not always a focus of the clinically-oriented programs. I might grant that the variance is greater in psychology due to those schools, but when you factor out the schools that, in my view, should not exist in the first place, I think you would find the variance shrinks dramatically.

I will say that if there is one thing I have learned - it is that if I ever have a family member in need I would much rather send them to some sort of academic setting, be it a psychiatrist with a med school appointment, a psychology clinic, etc. than any other. There are plenty of good people out in the community, but I feel like its a huge roll of the dice and there is really no way for a layperson to know going in what to expect - we can get some sense for people's reputation within a field but even hearing from patients is not a great way to go as I have seen plenty of cases where people loved their social worker/psychologist/psychiatrist despite the fact that they were doing things that clearly had no hope of helping. A layperson just looking for who their insurance will cover has really no hope of figuring this out, and is probably in a poor position to evaluate their care most of the time - especially given the nature of the population we work with.

I'm venturing out more into practica and getting to know a bit more of what goes on in the real world and frankly, I just think the variability in quality of mental health as a whole is horrific. Every field has its wackos but I think the history in this field and the fact that we have only recently started developing the tools to take a more scientific approach has resulted in just ridiculous practices going on left and right...and disturbing tolerance for them in most places. Its a shame, but it DOES mean there is a lot of room for growth in the future and it means that we can do an incredible amount of good for a great number of people if we strive to rise above the pack.

 

[sunlioness]

Want to make 250k.
Make up some crackpot scheme, like left nostril breathing therapy or something, apply CBT principles and say its new. Use it for the latest thing in the news.

Then sell it!

LNBT is mine.

It wouldn't be any wilder than this. A therapist who liked to refer to me would swear by this stuff. Always kind of made me uncomfortable to accept referrals from her and hear her talk about doing it with shared patients. This is another total tangent, but it's always interesting to me that all these "out there" unsupported therapies that are charging people the big bucks to get trained in always seemed to be targeted at treating trauma. TAT isn't the only one. I can easily name 2-3 off the top of my head not including EMDR, which at least has some data behind it. I wonder why that is?

 

[erg923]

I also agree that there is wide variability in both fields, so Im not sure how pointing this out in regards to psychologists helps further the argument that is trying to be made. I do think that, rather than a sarcastic appeal for empirical support for manicsleep's argument, the most appropriates questions, IMHO, would be:

1. Well, what does this mean to you? Is there a "Less than I" inference that comes from this belief? Do you feel this effects your ability to work collaboratively or take suggestions from psychologists with a multidisciplinary treatment team setting?

2. Yes, I am aware that you can legally bill 96118, but I'm not sure I understand why you want to? I have always been taught that the differences in training result in differing roles for the two practitioners, no? Thus, the act that you can (from a billing perspective) perform a 6 hour diagnostic neuropsych eval, complete with an MMPI-2 means...what exactly? Would this really be appropriate? Is that your role? Or was the point to demonstrate that you simply could do this if you wanted?


I really have no arguments with the assertion that psychiatrists can be just as successful and knowledgeable in academic research as a clinical science trained clinical psychologist. I think this is pretty obvious just by browsing pubmed. They often have to play some catch up in terms of stat procedures and design issues at first, but within a productive academic setting, I don't feel its a big set back at all.