Boutique psychotherapy

[EC3]

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What is the most effective (and efficient) path to becoming a successful boutique psychotherapist?

Also does anyone know any practitioners and have any recommendations or feedback? Is there a lot of paperkwork to document patient encounters? What about business overhead?

thx for any help that can be offered.

 

[strangeglove]

beware the wrath of OldPsychDoc...

 

[OldPsychDoc]

beware the wrath of OldPsychDoc...

Actually, I was just more curious about how it was that an interest in psychotherapy emerged in the past 24 hours in this budding pathologist's brain? (Especially as he states that he hates doing interviews! 😕)

 

[Doc Samson]

Actually, I was just more curious about how it was that an interest in psychotherapy emerged in the past 24 hours in this budding pathologist's brain? (Especially as he states that he hates doing interviews! 😕)

I particularly enjoyed the reference to "working and getting the hell out of there."

Boutique psychotherapy = patients wealthy enough to pay out of pocket = lots of cluster B action = them expecting you to be available by pager 24/7

 

[EC3]

Actually, I was just more curious about how it was that an interest in psychotherapy emerged in the past 24 hours in this budding pathologist's brain? (Especially as he states that he hates doing interviews! 😕)

thanks for the informative and thought-filled response 🙄 😴

 

[EC3]

I particularly enjoyed the reference to "working and getting the hell out of there."

Boutique psychotherapy = patients wealthy enough to pay out of pocket = lots of cluster B action = them expecting you to be available by pager 24/7

so there is a lot of "call" or are you just goofing around like the other poster?

 

[EC3]

and to future posters, this is a serious question. i had a family friend talk to me about this and was curious as to what is actually entailed within a practice of this type.

if you're not going to bother posting a serious response, please don't clutter an otherwise legitimate thread with trash. sorry to come of as a b*#$@ but i'd prefer not having this thread progress into nonsense. thx.

 

[OldPsychDoc]

and to future posters, this is a serious question. i had a family friend talk to me about this and was curious as to what is actually entailed within a practice of this type.

if you're not going to bother posting a serious response, please don't clutter an otherwise legitimate thread with trash. sorry to come of as a b*#$@ but i'd prefer not having this thread progress into nonsense. thx.

Sorry to come off as an a$$h013, but basically, if you really don't care to work your butt off dealing with needy, difficult, unpleasant, and sometimes unkind patients with seriously f'd up lives, you shouldn't even be thinking about going into psychiatry, even if your goal is an upper class "boutique practice".

Forgive me for doing a brief "background check" in an attempt to acquire some insight into your level of interest, as your username was not a familiar one on this forum.

 

[MBK2003]

High prestige residency training in city with large number of hedge fund / trust fund babies (i.e. NYC or SF) + Academic affiliation with prominent major medical center + psychoanalytic training at prominent psychoanalytic training institute + availability for early morning, late evening, and weekend appointments + numerous publications in the field of your specific psychotherapy + ability to cultivate a good referral network through your interpersonal relationships with colleagues + either the patience of Kohut or the tenacity of Kernberg = full fee cash-only private psychotherapy practice

In reality, though, the big bucks people that I know do high-end psychopharm practice - e.g. $1500 for a 45 minute evaluation, $600 per 30 minute med visit.

If that's what you're after the equation varies slightly : High prestige residency training in city with large number of hedge fund / trust fund babies (i.e. NYC or SF) + Academic affiliation with prominent major medical center + first authorship of major NIMH funded research study published in NEJM + leadership position in the crafting of DSM-V + availability for early morning, late evening, and weekend appointments + numerous publications in the field of your specific expertise + ability to cultivate a good referral network through your interpersonal relationships with colleagues = full fee cash-only private psychopharm practice

Good luck with that!

MBK2003 - a future psychiatrist to children unencumbered by a trust fund

 

[EC3]

Sorry to come off as an a$$h013, but basically, if you really don't care to work your butt off dealing with needy, difficult, unpleasant, and sometimes unkind patients with seriously f'd up lives, you shouldn't even be thinking about going into psychiatry, even if your goal is an upper class "boutique practice".

Forgive me for doing a brief "background check" in an attempt to acquire some insight into your level of interest, as your username was not a familiar one on this forum.

spare me the selfless, life-calling, must-save-the-planet rhetoric; there's no law telling me how i must use my degree. i don't knock you for getting your pleasure with dealing with those types of patients, so please don't pass judgment on where my interests may lie. despite what you think, people do benefit from "boutique" practices... maybe it doesn't fit into your paradigm, but who are you that you think others must care about your standards?

 

[EC3]

High prestige residency training in city with large number of hedge fund / trust fund babies (i.e. NYC or SF) + Academic affiliation with prominent major medical center + psychoanalytic training at prominent psychoanalytic training institute + availability for early morning, late evening, and weekend appointments + numerous publications in the field of your specific psychotherapy + ability to cultivate a good referral network through your interpersonal relationships with colleagues + either the patience of Kohut or the tenacity of Kernberg = full fee cash-only private psychotherapy practice

In reality, though, the big bucks people that I know do high-end psychopharm practice - e.g. $1500 for a 45 minute evaluation, $600 per 30 minute med visit.

If that's what you're after the equation varies slightly : High prestige residency training in city with large number of hedge fund / trust fund babies (i.e. NYC or SF) + Academic affiliation with prominent major medical center + first authorship of major NIMH funded research study published in NEJM + leadership position in the crafting of DSM-V + availability for early morning, late evening, and weekend appointments + numerous publications in the field of your specific expertise + ability to cultivate a good referral network through your interpersonal relationships with colleagues = full fee cash-only private psychopharm practice

Good luck with that!

MBK2003 - a future psychiatrist to children unencumbered by a trust fund

i'm relatively unfamilar with psych programs. what makes a good psych applicant for the top programs? thx.

 

[MBK2003]

i'm relatively unfamilar with psych programs. what makes a good psych applicant for the top programs? thx.

As an amalgated example of myself and/or several colleagues at a typical top 10 psych program:
Step 1 and 2 >255
AOA
Honors in all MS 3 electives
LOR from luminary in the field
8-10 peer-reviewed journal publications - 2-4 as first author
PhD or substantial research in basic science

Not to be too snarky, but if you want to play with the big boys and girls, you need to have the creds from the start of the game and be willing to demonstrate that you can work harder than the rest. If you are looking to do psych because of the lifestyle or the hours, you aren't going to be the top tier "boutique" psychiatrist to the well-heeled. I know several of our faculty who have these practices and frankly they work 70-80 hours per week.

MBK2003

 

[strangeglove]

As an amalgated example of myself and/or several colleagues at a typical top 10 psych program:
Step 1 and 2 >255
AOA
Honors in all MS 3 electives
LOR from luminary in the field
8-10 peer-reviewed journal publications - 2-4 as first author
PhD or substantial research in basic science

MBK2003

That's a bit excessive, wouldn't you say? I'd say any 3 of these qualifications would probably be adequate (I speak from experience). That being said, while it is generally easier to match into psych than most other specialties, it is perhaps as difficult at the top of the heap, since the applicants who get into these programs usually aren't the ones who are going into psych because they can't match into derm.

 

[OldPsychDoc]

i'm relatively unfamilar with psych programs. what makes a good psych applicant for the top programs? thx.

Ummm--actually caring about psychiatric patients is a good start...🙄

 

[MBK2003]

That's a bit excessive, wouldn't you say? I'd say any 3 of these qualifications would probably be adequate (I speak from experience). That being said, while it is generally easier to match into psych than most other specialties, it is perhaps as difficult at the top of the heap, since the applicants who get into these programs usually aren't the ones who are going into psych because they can't match into derm.

Good point, top 10 programs are filled with people who could have matched in derm, plastics, or rads if they had chosen that career path. It's the middle to bottom 1/3 of programs where the relative competitiveness of the applicants falls off. That said, if someone is looking to build a "boutique" practice, it's built on the lay person prestige of the residency program. So, for instance, while Western Psych in Pittsburgh may be the absolute bomb in research funding and research track residency training, to a narcissistic millionaire in a major east coast city, a Harvard program trained psychiatrist will be a much more appealing proposition.

Ummm--actually caring about psychiatric patients is a good start...

While that's considered a given, I thought that we were carrying on an esoteric hypothetic discussion about how someone could make lots of money for little investment of time and effort. The classic resistance my more defended patients take up in session to avoid actually discussing their more painful issues ...

MBK2003

 

[OldPsychDoc]

spare me the selfless, life-calling, must-save-the-planet rhetoric; there's no law telling me how i must use my degree. i don't knock you for getting your pleasure with dealing with those types of patients, so please don't pass judgment on where my interests may lie. despite what you think, people do benefit from "boutique" practices... maybe it doesn't fit into your paradigm, but who are you that you think others must care about your standards?

I'm hardly selfless--I'm earning a comfortable living, thank you.
I also have no delusions about saving any planets--as we say in this business, the lightbulb has to want to change. I'm just here to lend a hand.

However, you ask about the most effective path to this boutique practice. Unfortunately for you, it must invariably involve matching into and completing a psychiatric residency. I say unfortunately, because this process involves a lot of interviews with difficult patients, too much annoying paperwork, and a lot of long days on the wards "farting around pontificating". It is hard for me to imagine you being a happy resident in these circumstances. And unhappy residents rarely become the kind of satisfied psychiatrists who can pursue the type of practice that you envision.

As to who I am to expect that others care about my standards--I am just another interviewer trying to fill our program with those most suited for psychiatry--which in my definition is those who are most interested in caring for psychiatric patients. Just trying to save you and your future colleagues some pain, that's all.

Good luck in your endeavors.

 

[Doc Samson]

so there is a lot of "call" or are you just goofing around like the other poster?

Boutique practice requires 24/7 availability. Your well-healed patients will expect to be getting "the best" for their money, which means access to you (not an answering service, not a colleague) whenever they want, except for maybe 2-3 weeks of vacation/year. Just the other week I had a boutique therapist fly cross-country to pick up a wealthy hypomanic patient who showed up in our ED.

It terms of the "snarky responses" - psychiatry (training and practice) requires an awful lot of patience and a real enjoyment and understanding of what you do. Perhaps more than any other specialty, an unhappy psychiatrist (or a psychiatrist who's in it for the myth of the lifestyle) has little tolerance for their patients' complaints, inevitably resulting in poor treatment. Your colleagues (i.e. us) tend to be very protective of our patients because we see them get mistreated a lot. We don't like internists or surgeons who mistreat the mentally ill - but we abhor psychiatrists who do so.

 

[Doc Samson]

so there is a lot of "call" or are you just goofing around like the other poster?

Boutique practice requires 24/7 availability. Your well-heeled patients will expect to be getting "the best" for their money, which means access to you (not an answering service, not a colleague) whenever they want, except for maybe 2-3 weeks of vacation/year. Just the other week I had a boutique therapist fly cross-country to pick up a wealthy hypomanic patient who showed up in our ED.

It terms of the "snarky responses" - psychiatry (training and practice) requires an awful lot of patience and a real enjoyment and understanding of what you do. Perhaps more than any other specialty, an unhappy psychiatrist (or a psychiatrist who's in it for the myth of the lifestyle) has little tolerance for their patients' complaints, inevitably resulting in poor treatment. Your colleagues (i.e. us) tend to be very protective of our patients because we see them get mistreated a lot. We don't like internists or surgeons who mistreat the mentally ill - but we abhor psychiatrists who do so.

 

[robberbaron]

[


quote=MBK2003;5262615]As an amalgated example of myself and/or several colleagues at a typical top 10 psych program:
Step 1 and 2 >255
AOA
Honors in all MS 3 electives
LOR from luminary in the field
8-10 peer-reviewed journal publications - 2-4 as first author
PhD or substantial research in basic science

Not to be too snarky, but if you want to play with the big boys and girls, you need to have the creds from the start of the game and be willing to demonstrate that you can work harder than the rest. If you are looking to do psych because of the lifestyle or the hours, you aren't going to be the top tier "boutique" psychiatrist to the well-heeled. I know several of our faculty who have these practices and frankly they work 70-80 hours per week.

MBK2003[/quote]

Yeah right! I don't know anyone with all those credentials, even among my friends doing rad-onc and ortho at ivy hospitals. Give me a break! You described the profile of perhaps the top 10 med students in the country.

 

[Doc Samson]

[


quote=MBK2003;5262615]As an amalgated example of myself and/or several colleagues at a typical top 10 psych program:
Step 1 and 2 >255
AOA
Honors in all MS 3 electives
LOR from luminary in the field
8-10 peer-reviewed journal publications - 2-4 as first author
PhD or substantial research in basic science

Not to be too snarky, but if you want to play with the big boys and girls, you need to have the creds from the start of the game and be willing to demonstrate that you can work harder than the rest. If you are looking to do psych because of the lifestyle or the hours, you aren't going to be the top tier "boutique" psychiatrist to the well-heeled. I know several of our faculty who have these practices and frankly they work 70-80 hours per week.

MBK2003

Yeah right! I don't know anyone with all those credentials, even among my friends doing rad-onc and ortho at ivy hospitals. Give me a break! You described the profile of perhaps the top 10 med students in the country.[/QUOTE]

Having reviewed applications to a top 10 psychiatry residency for the past 4 years, I'd say you be surprised at just how many applicants have credentials very similar to these. The one thing I'd add to the list though, is great interpersonal skills that allow you to interview well - without this many of the above qualifications quickly lose their sparkle.

 

[i61164]

"farting around pontificating"

I look forward to this.

 

[Doc Samson]

I look forward to this.

It really is one of the highlights of the job.

 

[BabyPsychDoc]

spare me the selfless, life-calling, must-save-the-planet rhetoric; there's no law telling me how i must use my degree. i don't knock you for getting your pleasure with dealing with those types of patients, so please don't pass judgment on where my interests may lie. despite what you think, people do benefit from "boutique" practices... maybe it doesn't fit into your paradigm, but who are you that you think others must care about your standards?

Taking control of your own temper and learning to be nice to one's colleagues would be a good start for a future psychiatrist. 🙄

 

[PsychMD2100]

You have to be comfortable surrounding yourself with patients that most of society would find repulsive. If you're going for the cash grab, do Botox or dietary supplements. Psych is way too painful if you don't have a genuine interest in it.

That being said, I hope to have a combined academic/boutique practice in the not-too-distant future.

Good luck.

 

[EC3]

I'm hardly selfless--I'm earning a comfortable living, thank you.
I also have no delusions about saving any planets--as we say in this business, the lightbulb has to want to change. I'm just here to lend a hand.

However, you ask about the most effective path to this boutique practice. Unfortunately for you, it must invariably involve matching into and completing a psychiatric residency. I say unfortunately, because this process involves a lot of interviews with difficult patients, too much annoying paperwork, and a lot of long days on the wards "farting around pontificating". It is hard for me to imagine you being a happy resident in these circumstances. And unhappy residents rarely become the kind of satisfied psychiatrists who can pursue the type of practice that you envision.

As to who I am to expect that others care about my standards--I am just another interviewer trying to fill our program with those most suited for psychiatry--which in my definition is those who are most interested in caring for psychiatric patients. Just trying to save you and your future colleagues some pain, that's all.

Good luck in your endeavors.

would it not have been as fun if you just said something like this from the get-go? thanks for your serious input and reply this time.

 

[EC3]

Taking control of your own temper and learning to be nice to one's colleagues would be a good start for a future psychiatrist. 🙄

I appreciate the unsolicited psychoanalysis. Have your billing dept. get in touch with me, I'm sure you can squeeze a few RVUs from your original post.

 

[juddson]

As an amalgated example of myself and/or several colleagues at a typical top 10 psych program:
Step 1 and 2 >255
AOA
Honors in all MS 3 electives
LOR from luminary in the field
8-10 peer-reviewed journal publications - 2-4 as first author
PhD or substantial research in basic science
week.

MBK2003

This is a bit ridiculous, don't you think? Come on now.

Justin

 

[Doc Samson]

This is a bit ridiculous, don't you think? Come on now.

Justin

Like I said, applicants with these qualifications are not unusual at top-tier programs. They do not, however, consitute all of the folks who match at top-tier programs since psychiatry programs also tend to emphasize those ever-elusive "people skills."

 

[billypilgrim37]

Those things might not be unusual, but they aren't reflective of what one needs to accomplish to go to a "top10" psychiatry program. Looking at things like AOA and M3 rotation evals, that's pretty dependent on what medical school you're coming from. There are plenty of average kids at high-tier med schools who would have been AOA at middle-tier medical schools. Same thing is true for the LOR from a "luminary:" most schools don't have luminaries, and most students who go to schools that do may never have any access to them. Those research credentials are a bit insane as well for someone NOT enrolled as an md/phd or who has taken time off from school for research, albeit I'm sure it's happened before. A look at the residents on psychiatry program websites seem to suggest that almost no place has a majority of md/phds as their residents.

I'm sure you'll run across brilliant people with brilliant resume's like this. But to suggest that these are any sort of typical picture for psych residents at top programs seems a bit ambitious.

Top 10 programs, times an average of maybe 10 slots for each program, means there are around 100 med students who go on to top psychiatry programs. I'm sure a handful of them meet this very rigorous criteria, but that seems to suggest there are still a good number of slots available for very highly qualified but more "human" candidates as well.

 

[robberbaron]

Having reviewed applications to a top 10 psychiatry residency for the past 4 years, I'd say you be surprised at just how many applicants have credentials very similar to these. The one thing I'd add to the list though, is great interpersonal skills that allow you to interview well - without this many of the above qualifications quickly lose their sparkle.[/quote]

Funny, but when I was a 3rd year our psych program director told us directly that if we passed Step I on one attempt that the sky was the limit as far as the match went. As someone who ultimately matched at a "top" program, I feel that it's a bit disingenuous to depict the typical applicant at a top psych program as a student with credentials that would insure a competitive match in virtually any specialty. Of course there are great applicants to the top programs in every specialty but to state that one needs perfect credentials to match at a highly ranked psych program is misleading and bit dangerous in that it will discourage good med students with merely good credentials from applying to competitive programs when they may have the ability to become great psychiatrists. I think psych is fascinating but let's face it, most med students don't agree and I'm very doubtful that you'd find dozens of these top of class candidates applying to the top psych programs.

 

[Doc Samson]

Having reviewed applications to a top 10 psychiatry residency for the past 4 years, I'd say you be surprised at just how many applicants have credentials very similar to these. The one thing I'd add to the list though, is great interpersonal skills that allow you to interview well - without this many of the above qualifications quickly lose their sparkle.

Funny, but when I was a 3rd year our psych program director told us directly that if we passed Step I on one attempt that the sky was the limit as far as the match went. As someone who ultimately matched at a "top" program, I feel that it's a bit disingenuous to depict the typical applicant at a top psych program as a student with credentials that would insure a competitive match in virtually any specialty. Of course there are great applicants to the top programs in every specialty but to state that one needs perfect credentials to match at a highly ranked psych program is misleading and bit dangerous in that it will discourage good med students with merely good credentials from applying to competitive programs when they may have the ability to become great psychiatrists. I think psych is fascinating but let's face it, most med students don't agree and I'm very doubtful that you'd find dozens of these top of class candidates applying to the top psych programs.[/QUOTE]

Just to clarify what I've already written here...

There are a good number of "superstar" candidates as measured by the list of qualities previously mentioned applying to top-tier psychiatry residencies, HOWEVER they do not typically constitute the lion's share of residency classes at these programs because psychiatry programs are also looking for the "well-rounded" personable candidates with a desire to help the mentally ill. As long as you score >230 on the boards, honor Psychiatry and Medicine, and have some documented proof of genuine interest in helping the mentally ill (volunteer work, research, etc.), you should be in with a shot of an interview at almost every program.

 

[outofhere]

This is my opinion.

You can't expect to have a successful boutique psychotherapy or psychopharm practice right out of residency/fellowship. For psychotherapy, you need to get further training through an institute, and that will take quite a few years. And, you have to pay your dues. Since your practice is dependent on referrals, you need to establish your reputation. You will have to earn a good reputation: for instance, you initially will have to say yes to pretty much all the referrals that come your way- and there will be 'doozies' in these referrals. You need to take these referrals, because, if you keep saying no to these internists, they will not even bother bringing up your name to their patients, since they will assume you would say no anyway. So, you do this for a while, as you fork over big $ to attend a psychoanalytic institute and get analysis yourself. Then, you will start to get referrals you actually want, and will fill up a practice slowly and eventually, probably in your forties, be able to have a full-time boutique practice. Notice I say full-time. It is hard to fill a full-time practice doing all psychotherapy, but if just want to do this a part-time, it probably won't take as long.
I know a number of therapists who do this, and they don't take insurance, and they don't take cluster Bs (anymore) and they do very well. And they are all my parents' age. Oh, and I do live in a major metropolitan area, where $ is no object by these patients.

 

[Jollygooddoc]

There are a good number of "superstar" candidates as measured by the list of qualities previously mentioned applying to top-tier psychiatry residencies, HOWEVER they do not typically constitute the lion's share of residency classes at these programs because psychiatry programs are also looking for the "well-rounded" personable candidates with a desire to help the mentally ill. As long as you score >230 on the boards, honor Psychiatry and Medicine, and have some documented proof of genuine interest in helping the mentally ill (volunteer work, research, etc.), you should be in with a shot of an interview at almost every program.

Phew... makes me feel MUCH better, with my humble 236, only 2 papers, no PhD and no AOA membership (not that this existed in Cambridge 10 years ago).

 

[BabyPsychDoc]

There are a good number of "superstar" candidates as measured by the list of qualities previously mentioned applying to top-tier psychiatry residencies, HOWEVER they do not typically constitute the lion's share of residency classes at these programs because psychiatry programs are also looking for the "well-rounded" personable candidates with a desire to help the mentally ill. As long as you score >230 on the boards, honor Psychiatry and Medicine, and have some documented proof of genuine interest in helping the mentally ill (volunteer work, research, etc.), you should be in with a shot of an interview at almost every program.

This makes sense now. Looking at the NRMP matching statistics, I was slightly surprised to find out that there was a number of AMGs with stellar credentials that did NOT match to any program. I thought that perhaps they just applied to a handful of highly competitive programs, but it is also possible that they applied widely but just did not do well in the interview due to poor interpersonal skills/lack of genuine interest in the specialty, etc. Thanks for your post.

 

[DrIng]

I would suggest that the areas of possibility for a boutique practice are a bit broader than people think. In the town where I am training there area ctualyl a very limited numbr of good psychotherapy trained psychiatrists, so it's actually quite easy for people to get referrals etc. So keep in mind that a boutique practice in part depends on the competition around you. if you are one of only a few psychotherapist in town your need for glossy credentials is less.. Just my two cents worth...