Could what happened to EM happen to psychiatry?

[PikminOC]

Midlevels may not be bright, but they are easier to work with. Physicians, especially psychiatrists, have a reputation for being very independent-minded, as opposed to team players. I'd prefer teaming up with a midlevel than my friends in a PP, unfortunately.

Mid-levels have unions they don't work one minute extra without extra pay.

And hospital systems don't care about shoddy care

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[tr]

I graduated from a top 5 residency program. 90% ended in "regular" jobs in normal hospitals or stayed in academia as faculty, research or fellowship. All of them had to "apply" for a job. A few started PP while taking insurance and most certainly aren't getting paid $800 an hour. Those are rare PP opportunities that need years to build in very select marketplaces. Having a big name definitely makes your name jump on an application but it doesn't get you an $800/hr job. lol. And even if it did, is catering to the hyperrich the minimal standard for a decent job? Theres a point where elitism becomes a joke on itself.

This is very interesting. I also did residency at a 'name-brand' place and the modal job afterwards was cash private practice, with fees in the range sluox describes. A few people went to Kaiser or county. Three of my coresidents started a group practice that took insurance but I think they phased it out not too many years later. I don't know about a salaried job in that range though.

I also have similar experience to sluox in that applying for a job seems unfruitful. I have actually tried once or twice to apply for jobs and it seemed really useless, like throwing your CV into a bonfire or something. Either there was just no response or I ended up talking to some mindless recruiter who seemed like they were on a different planet. Everything fruitful has been through personal contacts.

 

[VA Hopeful Dr]

Trouble is, psych docs are uniquely positioned to practice into very old age. Larger cohorts that practice longer could ultimately result in a glut in the market. I would encourage anyone to work hard, save hard, and get enough cash to be able to walk away regardless of their field. Be it a glut or massive changes in the way medicine is structured in the country, any number of factors could make you obsolete or miserable. Hope for a long, happy, successful career, but plan for what happened to path to happen to you

Sure (FM is similar in that respect), but I think the number of psychiatrists practicing at 80 is going to be quite small. So between the coming baby boomer retirement wave, increasing population, the massive variety of job types available to psychiatrists, and the fact that a psychiatry appointment everywhere I've ever worked was never less than 2 months.... I think y'all are safe as far as jobs.

Could this change in the next 20 years? Sure. But I think psychiatry and FM are going to be the last specialties in medicine that have this problem.

 

[PikminOC]

Better that there's more residency slots than no slot at all.

 

[clausewitz2]

Why would you think you'd "apply" for a job? I think this is where being an IMG very seriously disadvantage you. IMGs by and large have NO clue how starting a business in the US works. You get invited for such a job. I've never applied for a job that pays $800 an hour. In fact, I've never applied (seriously) for a job. LOL. People find me and they ask me how much I charge, and then they either agree to it or not. They offer me jobs and I make a counteroffer. If you go to a university program with a regional reputation you generally don't need to apply for jobs in psych.

You know this has been my experience as well. The closest I have come to applying for a job is sort of expressing general interest to someone in charge that I might like to work there, and then suddenly there are interviews and an offer.

My current main gig came about because I emailed as a PGY-3 asking if they'd ever had anyone moonlight for them. That was the extent of my application, alerting them I exist and wanted to work.

 

[dl2dp2]

I know people with Harvard - Yale pedigree that are working for high end residential pulling in $700/eval/hr. The guy contractor is definitely a med school/residency/fellowship snob. Law school and business school brands have a similar effect. Their networks just opens them up for different types of employment and opportunities. I don’t see why psychiatry would be different.

Yup. Bingo.

Also, I've said it many times: it's grossly mistaken that if you have a cash PP you only treat "hyperrich patients". Many *many* middle-class patients will gladly pay anywhere between $200 and $400 per half an hour once every 1-3 months for quality psychiatric care. And I think there's actually a lot of value add over their usual insurance-based service. They may just not pay you that if they can't pronounce your medical school. What can I say? People care about brands.

 

[calvnandhobbs68]

Yup. Bingo.

Also, I've said it many times: it's grossly mistaken that if you have a cash PP you only treat "hyperrich patients". Many *many* middle-class patients will gladly pay anywhere between $200 and $400 per half an hour once every 1-3 months for quality psychiatric care. And I think there's actually a lot of value add over their usual insurance-based service. They may just not pay you that if they can't pronounce your medical school. What can I say? People care about brands.

Right, I mean think about physicians even and how many of them want to pay for psychiatry for themselves/their kids out of network. I could use my HSA to pay for out of pocket medical services (so pre-tax) even if it doesn't count towards my deductible, which means I'm probably paying about 18-20% less than post-tax money I'd use for anything else (even more tax benefit if I was making attending money). There are tons of people making 75K+ (or even 100K+) that pay 100 bucks a month for cable and 100 bucks a month for their cell phone that will pay $175-200 for a psychiatry followup with someone they like and who they can get in with or contact in a reasonable timeframe.

 

[Mad Jack]

Yup. Bingo.

Also, I've said it many times: it's grossly mistaken that if you have a cash PP you only treat "hyperrich patients". Many *many* middle-class patients will gladly pay anywhere between $200 and $400 per half an hour once every 1-3 months for quality psychiatric care. And I think there's actually a lot of value add over their usual insurance-based service. They may just not pay you that if they can't pronounce your medical school. What can I say? People care about brands.

Eh, even a psych NP in my home area is charging $250 for follow-ups and $350 for initial evals and she has a thriving practice in a very wealthy suburb. There is such a shortage in many areas that anyone can build a very lucrative practice. Like, I haven't even finished residency and I'm a nobody from nowhere and I've got patients asking if they can see me via telehealth for cash when I head off to fellowship. There's crazy demand and limited supply, particularly of personable psychiatrists that make people feel comfortable and provide them with physician-level service. You may not land some clients or be taken into some practices, but word of mouth, good marketing, and good business acumen can go a long way.

 

[psychacad]

This is very interesting. I also did residency at a 'name-brand' place and the modal job afterwards was cash private practice, with fees in the range sluox describes. A few people went to Kaiser or county. Three of my coresidents started a group practice that took insurance but I think they phased it out not too many years later. I don't know about a salaried job in that range though.

Yes, a couple of those programs are in those select areas where there's a market for "concierge" cash PP (easy to tell), but not all of them are. However, I'm very skeptical about the $800/hr as a standard. This is easily verifiable. You're usually looking more like $400-$500.

In any case, is this now what we are holding for a standard for a good job? That was really the point.

 

[clausewitz2]

Yup. Bingo.

Also, I've said it many times: it's grossly mistaken that if you have a cash PP you only treat "hyperrich patients". Many *many* middle-class patients will gladly pay anywhere between $200 and $400 per half an hour once every 1-3 months for quality psychiatric care. And I think there's actually a lot of value add over their usual insurance-based service. They may just not pay you that if they can't pronounce your medical school. What can I say? People care about brands.

One of my regular therapy self-pay clients is shelling out $300 weekly to see me and has for a few months now. They are currently unemployed. They make it work. I am sure the Oxbridge degree on my CV doesn't hurt.

EDIT: Of the self-pay folks I have who I remember off the top of my head, the occupations represented are: College student (not the kind with a trust fund). Med student. Psychologist. Physician. NP. customer service rep. engineer. insurance actuary. graphic designer. accountant. office drone. academic. PhD student. medical device rep. Lawyer. Social worker. Therapist.

So, like, not on public assistance for the most part, but also not plutocrat tycoons by any stretch of the imagination. It was one of the more pleasant surprises of PP for me that doing substantial self-pay business did not have to involve empathizing with the the agonies of buying off-brand yachts.

 

[sloh]

These psychiatry hourly compensation numbers are absolutely bonkers. Kudos to you guys

 

[Techmed07]

Yes, a couple of those programs are in those select areas where there's a market for "concierge" cash PP (easy to tell), but not all of them are. However, I'm very skeptical about the $800/hr as a standard. This is easily verifiable. You're usually looking more like $400-$500.

In any case, is this now what we are holding for a standard for a good job? That was really the point.

I think what is being reiterated is with a certain pedigree and personality you can attract and/or command a certain amount of pay. This is seen with T-10 law schools and business schools. The average salary of those graduate from Yale Law School is not the same as those who go to Texas Southern.

What has allowed medicine to circumvent the branding effect that MBA and Law Schools succumb to is the fact insurance companies don't care about pedigree. However, if you do not take insurance.. guess what the lay public does care about brand/pedigree. Consequentially, you see these differences come up with psychiatrists and other medicine specialties that can operate outside of insurance reimbursement. Stanford Yale Harvard is able to attract clientele who will pay top dollar. This has nothing to do with the quality of services.

 

[nowaysanjose]

Are we calling people clients now?

edit

 

[robellis]

These psychiatry hourly compensation numbers are absolutely bonkers. Kudos to you guys

They’re also grossly unrealistic for 95 percent of psychiatrists..psych doesn’t make much compared to the high paying fields on average, yes you will have outliers but there are also orthopods and neurosurgeons making 2million+, as much as we hate to admit it we will never make even close to the top

 

[clausewitz2]

Are we calling people clients now?

edit

Therapists sure do

 

[tr]

Yes, a couple of those programs are in those select areas where there's a market for "concierge" cash PP (easy to tell), but not all of them are. However, I'm very skeptical about the $800/hr as a standard. This is easily verifiable. You're usually looking more like $400-$500.

In any case, is this now what we are holding for a standard for a good job? That was really the point.

I have no head for business whatsoever and do not want the headaches of administering a private practice. I do participate in my current institution's 'faculty practice,' where the institution takes a big cut for handling the administrative stuff. Typical pricing in the FPA is $1000/intake, $450 for 30 min f/u, although you can set whatever price you want as an individual. Current institution has much less brand recognition than my former one and most of the people here do not have blingy type CVs.

At least one individual faculty member at my previous, more blingy institution, which did not regulate outside clinical work, charged multiple thousands of dollars for intakes in his outside private practice. (Which I learned from patients who couldn't afford that and made their way through a several month wait-list to see me within the institution instead, paid under insurance.)

I'm sure there are lots of people in lower COL areas charging <200/h, but there is a very very long tail on the top side of this distribution. Hence I bet average numbers are not too far off from what @sluox suggests.

 

[psychacad]

I think what is being reiterated is with a certain pedigree and personality you can attract and/or command a certain amount of pay. This is seen with T-10 law schools and business schools. The average salary of those graduate from Yale Law School is not the same as those who go to Texas Southern.

What has allowed medicine to circumvent the branding effect that MBA and Law Schools succumb to is the fact insurance companies don't care about pedigree. However, if you do not take insurance.. guess what the lay public does care about brand/pedigree. Consequentially, you see these differences come up with psychiatrists and other medicine specialties that can operate outside of insurance reimbursement. Stanford Yale Harvard is able to attract clientele who will pay top dollar. This has nothing to do with the quality of services.

There is an inherent contradiction in this argument. One part says you need a HYP background to charge these fees. The other part says there is so much need that apparently "middle class" people in big cities are standing in line to pay $800/hour every couple of weeks. Do you really think if that's the case the market would be restricted to a few Columbia/UCLA grads?

I think we strayed far enough from the initial point. Is the sky falling on non-"top tier" residency grads? I haven't seen any evidence for that.

 

[Sushirolls]

There is an inherent contradiction in this argument. One part says you need a HYP background to charge these fees. The other part says there is so much need that apparently "middle class" people in big cities are standing in line to pay $800/hour every couple of weeks. Do you really think if that's the case the market would be restricted to a few Columbia/UCLA grads?

I think we strayed far enough from the initial point. Is the sky falling on non-"top tier" residency grads? I haven't seen any evidence for that.

The whole thread is about future conjecture. So could just as easily say Canada invades now that Biden is in office and we're all Canadian health system employees.

 

[Techmed07]

There is an inherent contradiction in this argument. One part says you need a HYP background to charge these fees. The other part says there is so much need that apparently "middle class" people in big cities are standing in line to pay $800/hour every couple of weeks. Do you really think if that's the case the market would be restricted to a few Columbia/UCLA grads?

I think we strayed far enough from the initial point. Is the sky falling on non-"top tier" residency grads? I haven't seen any evidence for that.

Actually the points were —

1) that people don’t have to be Uber wealthy to shell out amount of money we are talking about.

2) People are more willing to do so if you have a brand.

3) The poster was suggesting that if mid-levels encroachment increases and there is glut of psychiatrists—those who will be least affected will be those with a brand somewhere on their CV. This has been seen with law schools and business school. He/She/Them/X was urging others to study hard and go to the best name brand medical school, and/or residency and/or fellowship they can get into. It’s a marketing/networking thing that pays off.


You are right on that the sky is not falling for any of us

 

[psychacad]

Actually the points were —

1) that people don’t have to be Uber wealthy to shell out amount of money we are talking about.

2) People are more willing to do so if you have a brand.

3) The poster was suggesting that if mid-levels encroachment increases and there is glut of psychiatrists—those who will be least affected will be those with a brand somewhere on their CV. This has been seen with law schools and business school. He/She/Them/X was urging others to study hard and go to the best name brand medical school, and/or residency and/or fellowship they can get into. It’s a marketing/networking thing that pays off.


You are right on that the sky is not falling for any of us

The single thread in all of that is a brand of elitism. If there's a market for high pay cash practice by regular people, then it wouldn't be an exclusive niche. At some point you have to pick one or the other.

Future conjectures should also be based on actual evidence.

 

[clausewitz2]

The single thread in all of that is a brand of elitism. If there's a market for high pay cash practice by regular people, then it wouldn't be an exclusive niche. At some point you have to pick one or the other.

Future conjectures should also be based on actual evidence.

Doesn't have to be exclusive to have the top end dominated by people with a certain kind of connections/CV/talent.

There are lots of people who are actors. There are not many people who are Will Smith. (though he is actually a chump income wise compared to Warwick Davis, man has been in like every major commercially successful franchise for decades).

More illustrative example - do you think that Nicholas Cage, magnificent weirdo that he is, would be mansion-rich if he wasn't Francis Ford Coppola's nephew?

It's not that you have to have a brand-name residency or school on your CV to have a successful private practice. You don't. It's that it's easier to sell yourself if you have selling points. some people are good enough at hyping themselves they don't need it - the smarmiest, most franchise-y, probably highest-grossing psychiatrist in my area went to WVU. But ceteris paribus a shiny CV is an advantage (and shiny in a recognizable-to-laypeople way) and you have a better chance of doing well if you have it.

 

[Techmed07]

And with that this thread comes to a close....

The answer to the question: “Highly unlikely”

 

[dl2dp2]

I have no head for business whatsoever and do not want the headaches of administering a private practice. I do participate in my current institution's 'faculty practice,' where the institution takes a big cut for handling the administrative stuff. Typical pricing in the FPA is $1000/intake, $450 for 30 min f/u, although you can set whatever price you want as an individual. Current institution has much less brand recognition than my former one and most of the people here do not have blingy type CVs.

Your FPA is charging lower than my FPA charges but higher than what I charge privately. Interesting. I actually think I catch a lot of FPA left overs who can't afford actual "real" FPA. This just shows you that big systems with their pricing monopoly is the cause of exploding healthcare costs. I'm a big bargain compared to if you want a lofty *faculty* at semi-fancy U. Of course much of this is "admin" and I end up getting more than the salaried faculty.

This also explains why the actual FPAs (read: old famous docs who are on various America's best list) are fine on FPA--they still make more than we do even after the institutional haircut.

 

[dl2dp2]

There is an inherent contradiction in this argument. One part says you need a HYP background to charge these fees. The other part says there is so much need that apparently "middle class" people in big cities are standing in line to pay $800/hour every couple of weeks. Do you really think if that's the case the market would be restricted to a few Columbia/UCLA grads?

I think we strayed far enough from the initial point. Is the sky falling on non-"top tier" residency grads? I haven't seen any evidence for that.

There's no contradiction. In the real world, the fees one pays to a cash psychiatrist actually varies along a gradient that has some correlation with the CV/experience of the MD. The market is not restricted to a few Columbia/UCLA grads: as I said, if you went to a university program with a regional reputation you can likely do reasonably well with a private practice in most middle to upper middle class areas. And this need not be a typical "cash" set up. I know of several cases where the profitable practice has a setup more similar to a traditional medical practice that takes insurance, with W2 income 250k K-1 income ~ 250k, and growing. "Good" private facility-based jobs (i.e. salaried jobs between 4-500k with RVUs) also exist but are rarer--though not that rare: Kaiser total comp at partner level is > 400k--and those tend to get taken by top tier grads as they are typically advertised by word of mouth, or are not immediate entry jobs (i.e. you get hired for a medical director job with production-based comp, you join a larger partnership after working a few years as an associate, etc). Typically these jobs are not replaceable by NPs--indeed, they are often designed to, for a lack of better word, exploit NPs.

If you don't have the cachet to recruit patients, your total income running a practice may or may not exceed what you might get being an employee. Hence lower-tier residency grads are rarer in cash PP. In particular, they usually can STILL get cash PP started if they charge low fees--but often the fees are on par or even lower than what insurance would reimburse. In this scenario, it's often advantageous to just join a facility as your salary is protected and you don't have to worry about marketing, etc.

I hope you are understanding what I'm explaining. You are dichotomizing things in a very extreme way. The reality is that the market converges to a continuous and dynamic equalibrium.

Public/academic/nonprofit driven jobs do not pay all that well and a generic facilities job pays about ~$275. Still, even in these cases, a good residency/post-residency career trajectory tends to get you ahead of the line, especially if the story makes sense (i.e. "I'm moving because my family lives here"). But you are correct in stating that the average IMG grad would end up, on average, in a job like that, and that these jobs are quite plentiful at the moment. However, these jobs are similar to a typical IM job (i.e. tend to be meat pusher jobs with low control), or @Sushirolls refers to as "big box" jobs, and are starting to get replaced by NPs. These jobs are definitely not the type of jobs that are making psych "the new derm" and driving more competitive matches, and IMO if/when US residency spot dramatically increases a la EM and derm and rad onc these jobs will be affected first because they typically see by lots and lots of applicants. I've also seen a decent amount of consolidation/corporatization in this area.

 

[comp1]

I do not get this concern at all. We cannot fill psych MD or psych NP positions and they're all cush VA jobs where the total compensation is near $300k a year for MDs. The job market is absolutely excellent and there's plenty of work for everyone. It sucks to be an employer right now, not a practicing MD or NP.

 

[tr]

Your FPA is charging lower than my FPA charges but higher than what I charge privately. Interesting. I actually think I catch a lot of FPA left overs who can't afford actual "real" FPA. This just shows you that big systems with their pricing monopoly is the cause of exploding healthcare costs. I'm a big bargain compared to if you want a lofty *faculty* at semi-fancy U. Of course much of this is "admin" and I end up getting more than the salaried faculty.

This also explains why the actual FPAs (read: old famous docs who are on various America's best list) are fine on FPA--they still make more than we do even after the institutional haircut.

I mean, I'm not totally sure it's feasible to fill 30+ clinical h/week at those rates. They look amazing in isolation but it's not like most of my hours are FPA. I'm 40% research right now and we all know what that pays.

The America's Best lists are a scam. There's no bar or evaluation system. They call everyone with an MD and when you graciously accept to be on their fancy list, they charge you $500 for an office plaque. I'm surprised you haven't heard from these people. Now when I see America's Best plaques I mentally downgrade the practitioner a couple of points for being a dupe.

I’m a Journalist. Apparently, I’m Also One of America’s “Top Doctors.”

Companies cash in by calling physicians “Super Doctor,” “Best Doctor” or “Top Doctor” and then selling them opportunities to boast about the honor. Experts call the accolades a “scam.” Giving me one highlights the absurdity.

www.propublica.org

 

[Trismegistus4]

I do not get this concern at all. We cannot fill psych MD or psych NP positions and they're all cush VA jobs where the total compensation is near $300k a year for MDs. The job market is absolutely excellent and there's plenty of work for everyone. It sucks to be an employer right now, not a practicing MD or NP.

The problem is that doctors are SWPLs who only want to live where there's a Whole Foods with fresh organic arugula and five different Asian fusion restaurants are within walking distance.

 

[clausewitz2]

The problem is that doctors are SWPLs who only want to live where there's a Whole Foods with fresh organic arugula and five different Asian fusion restaurants are within walking distance.

Please, Whole Foods is totally corporate and arugula is so 2009.

....mostly kidding.

 

[dl2dp2]

I do not get this concern at all. We cannot fill psych MD or psych NP positions and they're all cush VA jobs where the total compensation is near $300k a year for MDs. The job market is absolutely excellent and there's plenty of work for everyone. It sucks to be an employer right now, not a practicing MD or NP.

I just glanced at Charting for Outcomes 2020, and in the last 5 years, the number of spots went up by ~30%. Not as dramatic as EM but not as low as derm. This is in the context of US Senior number only went up about 6%.

As far as I know, few university flag ship programs are expanding. Hence all of the spots go to new programs, community programs, etc. I predict that in 10 years lower-tier residency grads who are IMGs will be directly competing with NPs for lower-tier jobs that will pay what is equivalent to our current telepsych 200-250k /year meat pushing jobs, or be geographically restricted, just like the EM/rad onc grads of today.

 

[Techmed07]

I just glanced at Charting for Outcomes 2020, and in the last 5 years, the number of spots went up by ~30%. Not as dramatic as EM but not as low as derm. This is in the context of US Senior number only went up about 6%.

As far as I know, few university flag ship programs are expanding. Hence all of the spots go to new programs, community programs, etc. I predict that in 10 years lower-tier residency grads who are IMGs will be directly competing with NPs for lower-tier jobs that will pay what is equivalent to our current telepsych 200-250k /year meat pushing jobs, or be geographically restricted, just like the EM/rad onc grads of today.

Those are fighting words. Why did EM increase their spots soo aggressively.
@slu
- Don’t forget boomers will retire and
- There is a huge need for mental health services and stigma is reducing

In ten years I think everybody will be fine.

 

[Stagg737]

There's no contradiction. In the real world, the fees one pays to a cash psychiatrist actually varies along a gradient that has some correlation with the CV/experience of the MD. The market is not restricted to a few Columbia/UCLA grads: as I said, if you went to a university program with a regional reputation you can likely do reasonably well with a private practice in most middle to upper middle class areas. And this need not be a typical "cash" set up. I know of several cases where the profitable practice has a setup more similar to a traditional medical practice that takes insurance, with W2 income 250k K-1 income ~ 250k, and growing. "Good" private facility-based jobs (i.e. salaried jobs between 4-500k with RVUs) also exist but are rarer--though not that rare: Kaiser total comp at partner level is > 400k--and those tend to get taken by top tier grads as they are typically advertised by word of mouth, or are not immediate entry jobs (i.e. you get hired for a medical director job with production-based comp, you join a larger partnership after working a few years as an associate, etc). Typically these jobs are not replaceable by NPs--indeed, they are often designed to, for a lack of better word, exploit NPs.

If you don't have the cachet to recruit patients, your total income running a practice may or may not exceed what you might get being an employee. Hence lower-tier residency grads are rarer in cash PP. In particular, they usually can STILL get cash PP started if they charge low fees--but often the fees are on par or even lower than what insurance would reimburse. In this scenario, it's often advantageous to just join a facility as your salary is protected and you don't have to worry about marketing, etc.

I hope you are understanding what I'm explaining. You are dichotomizing things in a very extreme way. The reality is that the market converges to a continuous and dynamic equalibrium.

Public/academic/nonprofit driven jobs do not pay all that well and a generic facilities job pays about ~$275. Still, even in these cases, a good residency/post-residency career trajectory tends to get you ahead of the line, especially if the story makes sense (i.e. "I'm moving because my family lives here"). But you are correct in stating that the average IMG grad would end up, on average, in a job like that, and that these jobs are quite plentiful at the moment. However, these jobs are similar to a typical IM job (i.e. tend to be meat pusher jobs with low control), or @Sushirolls refers to as "big box" jobs, and are starting to get replaced by NPs. These jobs are definitely not the type of jobs that are making psych "the new derm" and driving more competitive matches, and IMO if/when US residency spot dramatically increases a la EM and derm and rad onc these jobs will be affected first because they typically see by lots and lots of applicants. I've also seen a decent amount of consolidation/corporatization in this area.

Is it the brand name itself that leads to those successful PPs (whether cash or not) or is it that those who have been driven enough to make it into top tier programs have the drive, knowledge, and cognitive flexibility to successfully open and run those successful clinics. The brand name obviously helps, and there will always be rich wasps who will look down on the docs who went to Brown instead of Harvard or Yale. But given the pedigree of the most successful PP docs I know, I'm doubtful that the brand name of the residency is what is really driving the highest paying positions. Correlation =/= causation.

 

[Techmed07]

I don’t think residents that graduate from top programs are all that more driven vs the rest of us. TBH. —- But I bet the laypublic thinks so. lol. That’s how Trump became president lol. Branding.

 

[clausewitz2]

Is it the brand name itself that leads to those successful PPs (whether cash or not) or is it that those who have been driven enough to make it into top tier programs have the drive, knowledge, and cognitive flexibility to successfully open and run those successful clinics. The brand name obviously helps, and there will always be rich wasps who will look down on the docs who went to Brown instead of Harvard or Yale. But given the pedigree of the most successful PP docs I know, I'm doubtful that the brand name of the residency is what is really driving the highest paying positions. Correlation =/= causation.

I mean, to assess this properly what you need is data on outcomes for people who were the also-rans at these high end places, say the next five on the program's match list below the lowest ranked person who matched there. See how mich of a discontinuity there is. There are econometric tools for analyzing this.

Good luck getting that data, though.

 

[Candidate2017]

"Good" private facility-based jobs (i.e. salaried jobs between 4-500k with RVUs) also exist but are rarer--though not that rare: Kaiser total comp at partner level is > 400k--and those tend to get taken by top tier grads as they are typically advertised by word of mouth, or are not immediate entry jobs

I'm not sure Kaiser is all that great. Perhaps I have some counter transference against my program, but I feel my program is middling, and we still place grads at Kaiser, some of whom are far from best of class.

Also, $400k-$500k is totally doable from insurance PP in my area once a panel is full. Not even partner, just contractor.

 

[Candidate2017]

The America's Best lists are a scam. There's no bar or evaluation system. They call everyone with an MD and when you graciously accept to be on their fancy list, they charge you $500 for an office plaque. I'm surprised you haven't heard from these people. Now when I see America's Best plaques I mentally downgrade the practitioner a couple of points for being a dupe.

Yes, but the uninformed public upgrades that psychiatrist 100 points. So maybe totally worth it for them. Plus, those nice, glossy Best Doctor ads in magazines.

 

[psychacad]

Also, $400k-$500k is totally doable from insurance PP in my area once a panel is full. Not even partner, just contractor.

This is actually the number that was quoted to me by those PP groups in SD for a full schedule. Both of them were willing to negotiate green card process (H1B was automatic) and, for anyone who knows anything about visas, green card processing is very costly and time intensive, and all I did was strut on LinkedIn. What a scary time to be a psychiatrist, LOL.

 

[AD04]

All of these big numbers being thrown around is all pie in the sky. People have been quoting me large numbers ever since middle of residency but when I test them, they are rarely true. You have to do the math. Yes, $800 / hr sounds good but how many billable hours a week? How many weeks a year? What is the cancellation or no-show rate? What is the retention rate? What is the collection rate? What is the overhead and the expenses?

If someone quotes you big numbers, ask for the math to back it up.

We need actual data from real practices to get an accurate picture of the landscape. But very few people are willing to share real numbers from their own practice. (Thank you @Sushirolls and @clausewitz2 for your openness.)

Regarding the importance of graduating from elite programs and making more money, I suspect a weak correlation if any.

I was invited to join 2 private practice ran by graduates of brand name residencies. As with any position I am considering, I always ask about compensation:

1. Yale. No other psychiatrists. Very popular metropolitan area in southeast. Private practice with some hospital work taking mostly Medicare. $300 k / year -- 50 - 60 hours / week.

2. Cornell. Other psychiatrists from various brand name residencies. Very popular metropolitan area in northeast. Private practice with some hospital work and some nursing home work which will bill out of network. $300 k / year -- 50 - 60 hours / week.

The reason the pay was so bad is because the business system they built up were inefficient. IMHO, the business system will be the main factor for your pay.

Is there someone with a full cash practice making $800 / hour, billing 40 hours / week, 50 weeks a year, with collection rate 95% or higher? It is possible but I suspect they are a very very small minority. I suspect most full-time cash practices allow the psychiatrist to make average income.

I know a cash psychiatrist who makes over $400k / year in northeast metropolitan area working around 40 hours / week, but he built up his practice over a few years. But is he really ahead of the employed psychiatrist when during the ramp up period is he making less -- especially when time value of money is factored in?

Many people here are fascinated with cash practice because of the allure to make a lot of money for a bit of time worked. But cash practice isn't the only way. It is a way -- and a low probability way at that. But for those who really want to get into cash practice and make above-average income, I would do the following:

1. Find a successful cash psychiatrist in a non-competing area and pay him to be your mentor. (Successful will be defined by a person making above-average income for below-average working hours. Have the mentor prove to you the numbers are real.)

2. Implement what your mentor tells you and continue to ask for feedback. Pay particular attention to marketing and patient acquisition. Continue to pay the mentor. This will ensure the longevity of the relationship.

3. Tweak your practice and repeat step 2. (Mentorship can stop if there is nothing else to learn.)

A good mentor would teach you his strategies and his system and will open up his network to you. If you cannot pay money, you will have to pay in another way, such as through sweat. Maybe you can work for your mentor for below-market rate, like what Warren Buffett did when he wanted to learn from Benjamin Graham.

At the end of the day, you will need to take risk if you want the reward. There is no free lunch, except for diversification.

 

[nexus73]

I'm not sure Kaiser is all that great. Perhaps I have some counter transference against my program, but I feel my program is middling, and we still place grads at Kaiser, some of whom are far from best of class.

Also, $400k-$500k is totally doable from insurance PP in my area once a panel is full. Not even partner, just contractor.

How many patients per day, and days per week is that?

 

[psychacad]

All of these big numbers being thrown around is all pie in the sky. People have been quoting me large numbers ever since middle of residency but when I test them, they are rarely true. You have to do the math. Yes, $800 / hr sounds good but how many billable hours a week? How many weeks a year? What is the cancellation or no-show rate? What is the retention rate? What is the collection rate? What is the overhead and the expenses?

If someone quotes you big numbers, ask for the math to back it up.

We need actual data from real practices to get an accurate picture of the landscape. But very few people are willing to share real numbers from their own practice. (Thank you @Sushirolls and @clausewitz2 for your openness.)

Regarding the importance of graduating from elite programs and making more money, I suspect a weak correlation if any.

I was invited to join 2 private practice ran by graduates of brand name residencies. As with any position I am considering, I always ask about compensation:

1. Yale. No other psychiatrists. Very popular metropolitan area in southeast. Private practice with some hospital work taking mostly Medicare. $300 k / year -- 50 - 60 hours / week.

2. Cornell. Other psychiatrists from various brand name residencies. Very popular metropolitan area in northeast. Private practice with some hospital work and some nursing home work which will bill out of network. $300 k / year -- 50 - 60 hours / week.

The reason the pay was so bad is because the business system they built up were inefficient. IMHO, the business system will be the main factor for your pay.

Is there someone with a full cash practice making $800 / hour, billing 40 hours / week, 50 weeks a year, with collection rate 95% or higher? It is possible but I suspect they are a very very small minority. I suspect most full-time cash practices allow the psychiatrist to make average income.

I know a cash psychiatrist who makes over $400k / year in northeast metropolitan area working around 40 hours / week, but he built up his practice over a few years. But is he really ahead of the employed psychiatrist when during the ramp up period is he making less -- especially when time value of money is factored in?

Many people here are fascinated with cash practice because of the allure to make a lot of money for a bit of time worked. But cash practice isn't the only way. It is a way -- and a low probability way at that. But for those who really want to get into cash practice and make above-average income, I would do the following:

1. Find a successful cash psychiatrist in a non-competing area and pay him to be your mentor. (Successful will be defined by a person making above-average income for below-average working hours. Have the mentor prove to you the numbers are real.)

2. Implement what your mentor tells you and continue to ask for feedback. Pay particular attention to marketing and patient acquisition. Continue to pay the mentor. This will ensure the longevity of the relationship.

3. Tweak your practice and repeat step 2. (Mentorship can stop if there is nothing else to learn.)

A good mentor would teach you his strategies and his system and will open up his network to you. If you cannot pay money, you will have to pay in another way, such as through sweat. Maybe you can work for your mentor for below-market rate, like what Warren Buffett did when he wanted to learn from Benjamin Graham.

At the end of the day, you will need to take risk if you want the reward. There is no free lunch, except for diversification.

I agree, there are probably faster and easier ways to make money than PP if you know where to look. No overhead, advertising, time investment, less actual effort on the job and all the other things needed to maintain it that suck time out of your day. PP is still great if you don't like having a boss, if you like therapy and really want to practice your own way.

 

[Techmed07]

After 8 years of medical school/residency—I need to pay somebody to be my mentor to open up a private practice.

Meanwhile Mark Zuckerburg dropped out of college and started a billion dollar company and there are plenty of tweens YouTube stars making millions lol. It’s a no for me dawg.

 

[jbomba]

After 8 years of medical school/residency—I need to pay somebody to be my mentor to open up a private practice.

Meanwhile Mark Zuckerburg dropped out of college and started a billion dollar company and there are plenty of tweens YouTube stars making millions lol. It’s a no for me dawg.
View attachment 328080View attachment 328080

In fairness Zuckerberg had to pay a lot of people to mentor or advise him on his way to that billion dollar company

 

[jbomba]

I agree, there are probably faster and easier ways to make money than PP if you know where to look. No overhead, advertising, time investment, less actual effort on the job and all the other things needed to maintain it that suck time out of your day. PP is still great if you don't like having a boss, if you like therapy and really want to practice your own way.

Where might one look?

 

[Techmed07]

If we can pass Step 1/2/3 and our boards. I think we can figure out how to run a business. Come on now. It’s like we are addicted to indentured servitude.

 

[dl2dp2]

If we can pass Step 1/2/3 and our boards. I think we can figure out how to run a business. Come on now. It’s like we are addicted to indentured servitude.

You don't necessarily need a business mentor. You just need to do some trial and error.

Clinically it can be quite useful to pay for supervision to discuss a more complicated case, etc.

$800 per hour is not common, that is true. But a "good" cash/insurance PP arrangement that ends up with PP profit > 500k at the partner level is not rare, ~ top 10-20% of jobs, which roughly correlates to the top 10-20% of university-based flagship residency programs. There's no contradiction and it roughly is consistent with MGMA, etc.

Again, comparing apples to apples, average anesthesia and derm jobs pay ~ 400k. You can get there in psych if you match well, work hard, etc. etc.

Work hard and match well and learn about running a business during residency and gain mentorship then is the most effective way forward in hedging against a possibly grim future where the expansion of residency spots and NPs leads to a death spiral. What else are you gonna do? Do urology? Come on. And if in 10 years the death spiral doesn't come then you'll have your choice of jobs. It's a win either way.

 

[Mad Jack]

You don't necessarily need a business mentor. You just need to do some trial and error.

Clinically it can be quite useful to pay for supervision to discuss a more complicated case, etc.

$800 per hour is not common, that is true. But a "good" cash/insurance PP arrangement that ends up with PP profit > 500k at the partner level is not rare, ~ top 10-20% of jobs, which roughly correlates to the top 10-20% of university-based flagship residency programs. There's no contradiction and it roughly is consistent with MGMA, etc.

Again, comparing apples to apples, average anesthesia and derm jobs pay ~ 400k. You can get there in psych if you match well, work hard, etc. etc.

Work hard and match well and learn about running a business during residency and gain mentorship then is the most effective way forward in hedging against a possibly grim future where the expansion of residency spots and NPs leads to a death spiral. What else are you gonna do? Do urology? Come on. And if in 10 years the death spiral doesn't come then you'll have your choice of jobs. It's a win either way.

Probably depends on the area- of the people that do well around here, nit absingle person has a fancy name on their CV. Their names are known in the community though, they *are* the brand. It's 100% business acumen and marketing. Maybe it's different in NYC, LA, Seattle, San Francisco, Miami, DC, and Boston, but most of the country doesn't live in these metros and there's still plenty of opportunity and a dearth of psychiatrists

 

[hamstergang]

If we can pass Step 1/2/3 and our boards. I think we can figure out how to run a business. Come on now. It’s like we are addicted to indentured servitude.

 

[dl2dp2]

Probably depends on the area- of the people that do well around here, nit absingle person has a fancy name on their CV. Their names are known in the community though, they *are* the brand. It's 100% business acumen and marketing. Maybe it's different in NYC, LA, Seattle, San Francisco, Miami, DC, and Boston, but most of the country doesn't live in these metros and there's still plenty of opportunity and a dearth of psychiatrists

But this is not inconsistent with what I'm saying:
in rad onc, you can't find a job in a major city that pays > 400k if you matched at a below 50%ile program.
In psych, you can't do well in a cash PP in a major city that pays > 400k if you matched at a below 50%ile program.

In psych you can still do well in a cash PP in a small city.
In rad onc, you apply around and can still find a job in a small city.

Etc. etc. If you want as many options as possible, work hard, match well, etc.

 

[Mad Jack]

But this is not inconsistent with what I'm saying:
in rad onc, you can't find a job in a major city that pays > 400k if you matched at a below 50%ile program.
In psych, you can't do well in a cash PP in a major city that pays > 400k if you matched at a below 50%ile program.

In psych you can still do well in a cash PP in a small city.
In rad onc, you apply around and can still find a job in a small city.

Etc. etc. If you want as many options as possible, work hard, match well, etc.

Fair. There's still plenty of big cities that you could do well in cash PP right out of the gate though, they're just not the glamorous cities. 270 million people don't live in the metros most people associate with "success." I don't think psych will reach the "if you don't have a great pedigree you're relegated to the sticks" point for at least 20 years.

 

[psychacad]

In psych, you can't do well in a cash PP in a major city that pays > 400k if you matched at a below 50%ile program.

This is nonsense and again not in line with my experience. A friend at a community program in the most expensive area of the country ("low tier DO") is building a thriving PP with focus on therapy. The trick? He did therapy training at one of those "name" programs in the city and is now faculty at said program. Of course the bigger trick is that he was good and gets referrals and support.

Another friend from the same program is faculty at Weill Cornell. ("an IMG with a med school you can't pronounce the name"). If he wants a PP and he's good at it, there's really nothing stopping him.

I would actually argue that being in a major city gives you access to connections regardless of program. Community program in big city>middle of nowhere. because it's much easier to expand your skill set, be exposed to different training environments and build connections. At the end of the day, people care about how good you are. There are awful residents from excellent programs as well.

No one is silly enough to think that residency name makes no difference but it isn't as critical as you try to make it. There's obviously a correlation between residency program and success, but that's just that. A correlation.

At the end of the day, we are all speaking from personal experience and I think that some institutions have indeed a more elitist and exclusive culture. But this experience doesn't necessarily generalize to the outer world.

 

[AD04]

If we can pass Step 1/2/3 and our boards. I think we can figure out how to run a business. Come on now. It’s like we are addicted to indentured servitude.

This is a post I would expect from someone without much business experience. It's about cost and opportunity cost. Spend 20 hours / week figuring something out vs spending 3 hours / week + $1,000 / week learning things the right way.

Some physicians who pass step 1 and 2 and 3 never figure it out.