If you are in private practice and consider accepting insured patients, managed care does not typically "like" to reimburse psychiatrists for psychotherapy; they would much prefer to reimburse the lower rates requested by non-MD therapists. Plus they may also restrict the nr. of covered of office visits that a particular pt. may have with a psych.-MD (like limit it for example to 6-12 visits per year.) This will not really be conducive to some types of psychotherapy. It depends a lot of the original insurance coverage. Some current insurances really have fairly limited "mental health" benefits.
If you are a salaried employee, you do not have much say re. how many patients you are supposed to see per day or re. your daily work structure, or your particular job description; you are pretty much operating on the employer's needs framework.
Ideally, a psychiatrist in private practice will eventually attempt to limit over time the hassles of having to deal with various managed-care types of insurances, or insurances with extraordinarily restrictive benefits. Most psychiatrists who are in private practice will also be interested actually to extend a patient base who will be able to either pay out of pocket or have some form of fee-for-service insurance (if any still exist at this time, I have no clue!). Then, one has more latitude and autonomy in regards to structuring the practice, e.g. having some pts. for certain types of therapies, other pts. for med checks plus psychotherapies, others for med checks alone. This type of payor mix and structure does NOT get built overnight. It is true, there is still great demand for competent psychiatric care in many many areas, however, realistically, when it comes to solo, one may find oneself geographically limited to a certain extent. Most affluent areas will have a glut of psychiatrists competing against one another for a good payor mix, but also a better payor mix and rapid practice build-up opportunities, other areas may be somewhere in the middle, others will be too poor to actually be able to support a new psychiatrist's full practice. I am trying to talk about it as objectively as possible, the way I see it...when it comes to "business issues". But the demand is STILL there, and is still pretty insatiable at this point in time. So theoretically, one can develop a successful private practice in most areas, with pretty good latitude re. practice structuring and autonomy regarding various personal interests. But it is NOT easy, and you really need to be very realistic as well. This may be actually more complicated than just hanging up a shingle! Some persons are more attuned to (and interested in) the business isues than others. I would venture to speculate that for many psychiatrists, sort of by nature, business interests are not always a big priority (focus of main interest, aptitude, or talent) in their lives, although of course if you want to survive in private practice, especially solo, and especially build it up yourself from scratch (which ensures maximum of autonomy and flexibility), you really need to learn about it! Typically, overhead costs will also be lower if you have an optimal payor mix. (Overhead costs are higher with a higher managed care proportion of pts., just because of the hassle of what one has to do and how much time one needs to put in, or additional help to hire, just for getting reimbursed by them!)
Another current possible scenario is some "behavioral health groups" or agencies who have been originated by non-MD's originally (like a group of LCSW's or PhD's/Psyd's), or by community agencies (like in some form of CMHC's), but who really would like to have a couple of psych-MD's on board...mostly for the meds. It may be lucrative. Some psychMD's like that. Some don't (mostly because very few psych. MD's like to see themselves used as "one trick ponies", and realistically, most psychiatrists are NOT such "ponies"...see below!).
There are also some multiple psychMD groups/partnerships around too (some are looser affiliations mostly for call coverage and maybe some expense-sharing, like billing services), some may be more structured, like a couple of "older" original owners/partners, who may bring a junior associate (eventual partner?) on board, but these days they could just as well be more interested in bringing in a NP rather than an MD, because MD's are much too expensive and hi-maintenance (at least this is the "folklore"!), relative to the business benefits of adding a partner. Of course, if it's your father and your uncle bringing you into the partnership, it's a different situation! Also, it's different if it's a private "faculty group practice" (affiliated with an academic setting).
Now, of course, ideally, a competent and comprehensively-trained psychiatrist in full solo private practice will not only take care to develop an optimal payor mix, but will also be aware of (and trained in) the various types of psychotherapies that may be applied and may be helpful in certain cases. Most psychiatrists who are currently practicing these days are not really "one trick ponies", meaning they are well aware of the definitions and applicability of various types of psychotherapies, and will have already received training (during residency), or at least exposure to several types of such therapies, and will have a good understanding of what "psychotherapy" really means (in its various forms), and how it may be usefully applied in various cases. Most psychiatrists will be able, via the initial comprehensive psychiatric evaluation to formulate some sort of tx. plan for their pt. that may include some types of psychotherapies that the psychiatrist himself/herself will conduct (in addition to med. management, or even w/out the med. management, since not everybody who seeks out a psychiatrist will absolutely need meds), or for which the pt. will be referred to another party. Not all patients who present to a psychiatrist's office will necessarily be interested or motivated for (or even benefit from) certain types of psychotherapy, or some pts. may require and benefit from certain types of psychotherapy, but not other types. Some will require and/or be interested in short-term therapies, others in longer-term therapies. Some pts. may only require to be seen a couple of times, mostly for a consultative-type specialized input regarding one specific issue, and will then not even need to see a psychiatrist anymore, long-term afterwards. I do not think I know one single psychiatrist out there these days that opens a practice with the goal in mind: "this will be a cognitive-behavioral psychotherapy practice", or this will be a short-term (brief) psychodynamic psychotherapy practice" (and nothing else), or this will exclusively be an "interpersonal therapy practice". Sure, some psychiatrists are more interested in and attuned to and trained in certain types of psychotherapies, vs. others. "Older" psychiatrists may have been also trained to be psychoanalysts, but I doubt that there are too many who are training in psychoanalysis these days, with the stated goal to open up an exclusive psychoanalytic practice. It is important for anyone looking into residency traininig to assess the breadth and depth of the psychotherapy training during residency, to have access to appropriate psychotherapy supervision during residency training, to inform oneself regarding the various types of psychotherapies, and to continually LEARN and clarify for themselves, as they progress in their training, what the originally rather fuzzy notion of "therapy" really means. (Of course, these days, finally ACGME plus Psych. people involved in training and education are doing a much better job regarding standardizing minimum necessary "psychotherapy competencies" in a broader fashion, accross the board, for most of all accredited psych. residency programs.)
In the real world, most psychiatrists in private practice these days maintain a variety of focus of interest regarding their daily activities or how they structure their practice. They may do combinations of outpt./inpt. or outpt./consultation work (meaning consultation not just for hospitalized patients, but also various agencies or organizations). It's an ongoing flexible thing. It's not static, by any means! A cynical person may even see it as "chasing the buck", but there's nothing wrong with chasing the buck if you are able to develop a good stream of referrals, maintain good relationships with colleagues and other community agencies, and continually strive to improve your practice structure in order to continue pursuing your original interests, and making $ at the same time, AND delivering competent highly specialized care at the same time! This would be the "ideal" form of solo practice. It IS an "ideal", of course. Psychiatrists have to pay their med school loans and ongoing bills too. So these days, you will see that many will continue to opt for employment, (at least part-time) rather than attempting to develop a full-time solo, from total scratch, at least at first, post-residency. The trick with being happily employed, I guess, is to KNOW who your employer is, and what exactly are they hiring you for (job description!). If the job description sounds overly narrow or, OTOH, too fuzzily comprehensive (like "we need a psychiatrist to do "everything"...outpt/inpts/consults/partial")...I would say...RUN! (or at least take it part-time rather than full-time!).
And, of course, there is academia/research too. (Including the possibility to take part in a faculty group private practice as well, for the ones so inclined!)
Sorry for the long post. I tried my best to present my perception about the current "practical state of things", in an as clear and demystified way as possible.
