Could what happened to EM happen to psychiatry?

[whacko]

As someone that practices in a suburban to rural market, I think hourly rates are more based on reputation, risk tolerance, and business acumen. Your reputation can be affected by where you went to residency but outside of saturated markets, I think psychiatrists put more credence into where you went that a typical patient. Once established, your reputation is more affected by word-of-mouth recommendations and reviews than your CV.

---

Members don't see this ad.

 

[dl2dp2]

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.

This is a different phenomenon. We are talking about fresh grad's options. If you went to no-name school and no name residency but through thick and thin got a faculty position somewhere fancy, or developed a local reputation, obviously that's a different story.

Hell if you do your fellowship somewhere fancy that can help, and we all know fellowships are easy as hell to get into. In fact many IMGs go train at named fellowships specifically to get the name on their CV.

I'm talking about the average below 50% grad with an average below 50% CV--you work at a community site job after residency or middle of the road practice, how do you compare apples with apples. If you are med student, if you are thinking about this field and in preparing yourself for the next decade, what are the possible pain spots, etc. Work hard match well and continue working hard to develop your practice after you graduate, and you'll be less likely to be relegated to bottom barrel jobs and compete with NPs.

 

[psychacad]

This is a different phenomenon. We are talking about fresh grad's options. If you went to no-name school and no name residency but through thick and thin got a faculty position somewhere fancy, or developed a local reputation, obviously that's a different story.

Hell if you do your fellowship somewhere fancy that can help, and we all know fellowships are easy as hell to get into. In fact many IMGs go train at named fellowships specifically to get the name on their CV.

I'm talking about the average below 50% grad with an average below 50% CV--you work at a community site job after residency or middle of the road practice, how do you compare apples with apples. If you are med student, if you are thinking about this field and in preparing yourself for the next decade, what are the possible pain spots, etc. Work hard match well and continue working hard to develop your practice after you graduate, and you'll be less likely to be relegated to bottom barrel jobs and compete with NPs.

None of them went through tick and thin. This isn't a 1/100 case. They just were good, motivated and made connections. Basic qualities for anyone who wants to be successful. I really think you underestimate how much flexibility there is out there. Heck, frankly, now that I think about it the ones who got "average" jobs just weren't interested in anything else. They were satisfied with that. Personally I would tell people to hedge their bets on trying to become the best psychiatrist they can be. Sometimes that means picking a brand program, sometimes it means moving to the location they see practicing in the future and utilizing the opportunities they have at their disposal.

 

[Techmed07]

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.

Or you can use the four years of residency trying to learn it instead of paying somebody lol. We all know the fourth year of psych residency is a waste of time.

 

[Techmed07]

Let's say in a hypothetical situation, NPs and/or midlevels do saturate the market where it impacts new Psych grads. Wouldn't that just mean that, like how in ER it's now advantageous to build a niche via a fellowship, Psych resident grads do the same by pursuing a fellowship?

The current SDN doctrine seems to suggest that only CAP fellowships are advantageous to one's career, but if market saturation affects supply (especially because I think the general public will end up confuse NPs for MDs/DOs) then it would be better to just do a fellowship of whatever may used as a marketable tool - then every concern talked about here is circumvented, save for a year of potential opportunity cost. Am I missing something here?

If so, it seems like the priority order of med students selecting a residency is 1) match at a name brand residency 2) match at a location with many name brand fellowships in the region...

Bingo

 

[Sushirolls]

Fellowships overall won't be a source of salvation for Psychiatry like Pathology.

CAP, is good.
Forensics could yield a niche.

Addiction nope.
Geriatrics nope.
C/L - shouldn't exist in the first place, perhaps for transplant but then call it that, transplant psych or something.
Talk of Neurostimulation fellowships in psych is a joke, bad idea and should be pushed back upon too.
Murmurs of EM Psych is also a joke and should be pushed back upon too. All you do is admit or discharge and if available 'Obs' for 24 hours.

 

[tortuga87]

This is a different phenomenon. We are talking about fresh grad's options. If you went to no-name school and no name residency but through thick and thin got a faculty position somewhere fancy, or developed a local reputation, obviously that's a different story.

Hell if you do your fellowship somewhere fancy that can help, and we all know fellowships are easy as hell to get into. In fact many IMGs go train at named fellowships specifically to get the name on their CV.

I'm talking about the average below 50% grad with an average below 50% CV--you work at a community site job after residency or middle of the road practice, how do you compare apples with apples. If you are med student, if you are thinking about this field and in preparing yourself for the next decade, what are the possible pain spots, etc. Work hard match well and continue working hard to develop your practice after you graduate, and you'll be less likely to be relegated to bottom barrel jobs and compete with NPs.

If you do not want to practice in Manhattan/SF/LA/[insert mega city] but a medium to large size city, is it better to go to MGH/Yale/Columbia for a one year fellowship, or just move directly to your desired location after residency and start your own PP? The second route intuitively seems better, but I'm not sure.

 

[dl2dp2]

If you do not want to practice in Manhattan/SF/LA/[insert mega city] but a medium to large size city, is it better to go to MGH/Yale/Columbia for a one year fellowship, or just move directly to your desired location after residency and start your own PP? The second route intuitively seems better, but I'm not sure.

Hard to say blanket. You'd have to look at the gestalt of the CV and professional profile. It also depends on what this other city is. Prior to making a decision, you might want to do some competitive analyses.

Fellowships overall won't be a source of salvation for Psychiatry like Pathology.

There's some value in doing a fellowship in certain circumstances. Say you are a random IMG who went to a random residency, I think there'll be some value-add in the private world for going for a research-ish geriatrics/addiction fellowship at "brand", then maybe get a volunteer faculty position at some university after. If you are already a graduate of a regional university program, and have no academic/administrative goals, I agree: get a real job. Fellowships are not value-add.

 

[psychacad]

Fellowships overall won't be a source of salvation for Psychiatry like Pathology.

CAP, is good.
Forensics could yield a niche.

Addiction nope.
Geriatrics nope.
C/L - shouldn't exist in the first place, perhaps for transplant but then call it that, transplant psych or something.
Talk of Neurostimulation fellowships in psych is a joke, bad idea and should be pushed back upon too.
Murmurs of EM Psych is also a joke and should be pushed back upon too. All you do is admit or discharge and if available 'Obs' for 24 hours.

Yet they are increasingly popular across the board. I'm puzzled why so many grads, even at the top5/top10 institutions, are choosing to do fellowships. And the range is CAP/forensic/CL/addiction and even geriatrics.

 

[Techmed07]

Why isn’t addictions a good move?

 

[nexus73]

I could be way off base here, but a major problem for ED doctors is they have all the patients they can have. Every patient that wants to be seen in an ED does get seen, and more. I'd argue many more people get seen without actual emergencies. The EDs provide such great access to care, that everyone who wants/needs to be treated in an ED will get in. So if you've got all the patients you can have, and you start adding even more doctors you run the risk of having an oversupply of ED doctors.

Psychiatry is in stark contrast. How many people who need to be seen by psychiatrists actually see one? Or even see a psych NP? Many people who should be managed by psychiatrists can't get access.

How many places have primary care mid levels managing a patient with schizoaffective disorder?

How many people with depression/anxiety are being managed by PCPs that would love to see a psychiatrist, and the PCP would love to refer them out to offload one of the 10 problems they're already dealing with in their 10 minute appt? But the PCP knows these patients will never get into the psychiatrist so doesn't even waste time with the referral.

How many people are depressed, anxious, OCD, PTSD etc that no one has identified because their symptoms are mild to moderate, and no one asks about it, and it just adds more work if you now have to add that onto the list of problems the PCP is dealing with? A lot.

So there is an under supply of psychiatry now for the patients that get referred to us. But I'd argue there is an immense number of patients that could be referred to us that aren't, either because PCPs know it's a pointless referral as they'll never get in, or patients aren't diagnosed and go untreated. I think if psychiatric access improves the apparent demand for psychiatric care will also increase as people can actually get into a psychiatrist. And health systems are recognizing that identifying psychiatric patients and getting into care saves them money, so in the coming years there is going to be increasing push to better recognize patients that need psychiatric help further increasing the demand for psychiatric care.

 

[Stagg737]

Why isn’t addictions a good move?

Too many pathways into addiction. You don't need to be a psychiatrist to have a fellowship in addictions medicine, from the ABAM website:

"American College of Academic Addiction Medicine-accredited fellowship programs provide subspecialty training, which is offered to physicians already trained in a specialty such as internal medicine, family medicine, pediatrics, psychiatry, emergency medicine, surgery, preventive medicine, or obstetrics and gynecology."

You also don't need a fellowship to work with many patients as methadone and suboxone certification are completely separate process. One residency program I rotated through all the residents after intern except one or two had their suboxone certifications. While it may be required at some facilities, there are many addictions positions that do not require a fellowship.

Obtaining it is much like the above ideas of being able to brand yourself as a sub-specialist, which many addictions patients won't really care about or understand unless they're coming from affluent settings.

 

[dl2dp2]

I think if psychiatric access improves the apparent demand for psychiatric care will also increase as people can actually get into a psychiatrist. And health systems are recognizing that identifying psychiatric patients and getting into care saves them money, so in the coming years there is going to be increasing push to better recognize patients that need psychiatric help further increasing the demand for psychiatric care.

The effects you are talking about on overall healthcare spending are generally inconsistent and insignificant. The more concerning phenomenon is the 30% increase in residency spots in 5 years. This effect will trounce all other effects for lower-tier graduates. Service utilization and availability of jobs are related in a very indirect way, and it takes a long time to achieve equilibrium: the growth of available jobs will lag. However, if the supply of job candidates go up dramatically, the competition amongst the same set of slowly growing jobs will increase dramatically as well, and this will push down salary, and this effect is *immediate*--this is actually exactly what the admins want and hoping for when they start residency programs. I.e. it's much more expensive to pay a staff position for 500k in nowhere desirably than get GME money for half a dozen FMGs and then offer one staff position for 250k down the line for one of them when they graduate.

 

[splik]

Even top academic centers are now replacing psychiatrists with NPs. Part of this is because it is becoming increasingly difficult to find psychiatrists willing to accept the poor pay. As NPs increasingly gain "full practice authority" they are even being appointed as "medical directors." Those who think they can't be replaced: think again. Most organizations don't care about what value you bring to patients or your diagnostic acumen and skills. They care about their bottom line and having cheap cannon fodder to staff their clinics. Private practice is now one of the last remaining vestiges that allows psychiatrists to practice without this threat. The writing is on the wall. I anticipate that VAs, academic medical centers, community mental health centers, and big hospital systems will increasingly hire NPs including into leadership roles. It has become a race to the bottom. If patients want physician led mental health care they are going to have to seek it elsewhere.

 

[Sushirolls]

Even top academic centers are now replacing psychiatrists with NPs. Part of this is because it is becoming increasingly difficult to find psychiatrists willing to accept the poor pay. As NPs increasingly gain "full practice authority" they are even being appointed as "medical directors." Those who think they can't be replaced: think again. Most organizations don't care about what value you bring to patients or your diagnostic acumen and skills. They care about their bottom line and having cheap cannon fodder to staff their clinics. Private practice is now one of the last remaining vestiges that allows psychiatrists to practice without this threat. The writing is on the wall. I anticipate that VAs, academic medical centers, community mental health centers, and big hospital systems will increasingly hire NPs including into leadership roles. It has become a race to the bottom. If patients want physician led mental health care they are going to have to seek it elsewhere.

Recently looked up the definition of Big Box Shop (Noun) in Merriam Webster's, and I think you just did a cut paste job for definition 1.

 

[splik]

Would you even recommend psychiatry to a medical student at this point? Seems like market saturation will occur due to midlevels in a variety of workplaces.

I enthusiastically recommend psychiatry to medical students who are genuinely interested in working with those with mental illness and making meaningful connections with their patients. They will do well in this field and will have a rewarding career. We can't predict the future, but physicians need to adapt to an evolving environment. If you are flexible, stay relevant, and do good work, you will be fine. None of this is new. Medicine is always changing and subject to the whims and fancy of whoever is in office at the time. That said, some of the observations in this thread could have equally applied in the 1940s and 50s. plus ça change, plus c'est la même chose.

 

[NewYorkChildPsych]

This is a fascinating thread.

Psychiatry is a great field -- arguably the best field -- with limitless opportunities to work in any type of environment. I have seen more mid-levels in and around New York (namely NPs who have started cash-only practices), but I haven't felt an impact on my private practice earnings/referrals or in my salaried position. I keep getting offers daily from headhunters or colleagues in the Northeast and elsewhere, and there's no shortage of families reaching out for care.

The writing may be on the wall, but I like to think that there is still demand for the time, attention, and expertise of the M.D., particularly in child/adolescent psychiatry.

 

[LimpSpatula]

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.

Sounds like heaping BS to me. Going to a university program is not going to open doors to $800/hr jobs for even 1% of psychiatrists. You selling pillows on the side or something buddy?

 

[psyguru]

Regarding NPs, they are not really a concern for me, particularly in my private forensic psychiatric expert witness practice or my faculty position in a neurorehab center.

 

[LimpSpatula]

Regarding NPs, they are not really a concern for me, particularly in my private forensic psychiatric expert witness practice or my faculty position in a neurorehab center.

Pretty soon NPs will be taking over telepsych, which will be the future of psychiatry. The pandemic is expediting this change. That’s the real problem.

 

[psyguru]

Pretty soon NPs will be taking over telepsych, which will be the future of psychiatry. The pandemic is expediting this change. That’s the real problem.

I don't see NPs replacing forensic psychiatric expert witnesses. The only place I may see an NP expert witness would be in med mal cases where an NP was involved. I was involved as an expert in such a case, and they retained me as well as an NP expert witness.

 

[dl2dp2]

Sounds like heaping BS to me. Going to a university program is not going to open doors to $800/hr jobs for even 1% of psychiatrists. You selling pillows on the side or something buddy?

To each his own. You don't have to believe me and I am not here to convince you.

 

[LimpSpatula]

To each his own. You don't have to believe me and I am not here to convince you.

Who are you here to convince then? I feel you are being disingenuous. If you’re trying to convince people to strive to be the best version of themselves and aim high, fine. But don’t pretend like this is some sort of viable path by simply going to a University program.

Yes kids, connections are important and bigger name programs attract bigger connections. Nepotism exists in medicine, just like the real world. But don’t feel bad if you graduated from a university program and aren’t getting offers for $800/hr.

 

[LimpSpatula]

I don't see NPs replacing forensic psychiatric expert witnesses. The only place I may see an NP expert witness would be in med mal cases where an NP was involved. I was involved as an expert in such a case, and they retained me as well as an NP expert witness.

For sure. I was speaking to general psychiatry.

 

[dl2dp2]

Who are you here to convince then? I feel you are being disingenuous. If you’re trying to convince people to strive to be the best version of themselves and aim high, fine. But don’t pretend like this is some sort of viable path by simply going to a University program.

Why isn't it? 40% of outpatient psychiatrists are cash only. They charge anywhere between $300 an hour and $800+ an hour. MGMA median is ~300k. 90%ile would be well over 400k. You better believe people who make 400k a year are billing > $500 an hour.

 

[LimpSpatula]

Why isn't it? 40% of outpatient psychiatrists are cash only. They charge anywhere between $300 an hour and $800+ an hour. MGMA median is ~300k. 90%ile would be well over 400k. You better believe people who make 400k a year are billing > $500 an hour.

Sure, but most aren’t billing $500/hr. I agree with you, in that going to a bigger name program opens up connections and your referral base would lend itself to billing at that rate. However, we’re still talking 90%. Possible? Yes. Likely? No. I’m not trying to come off abrasive, and I apologize for that.

I am all for physicians making as much as possible while feeling good about what they do.

 

[dl2dp2]

Sure, but most aren’t billing $500/hr. I agree with you, in that going to a bigger name program opens up connections and your referral base would lend itself to billing at that rate. However, we’re still talking 90%. Possible? Yes. Likely? No. I’m not trying to come off abrasive, and I apologize for that.

I am all for physicians making as much as possible while feeling good about what they do.

I think the issue here is whether and when psychiatry has a competitive advantage over other specialties in time to come ("is it gonna turn into EM"). IMO there's no advantage of a run-of-the-mill psychiatry job available for a lower-tier residency grad (vs. say IM), and whatever advantage it might have now (i.e. lower workload, more time and geographical flexibility) will erode with NP infusion. The high-end jobs are often unavailable to lower-tier grads, but obviously, that's not a one to one correspondence. The high-end jobs are much more desirable than a general IM job and are comparable to the best lifestyle jobs in medicine, but you need to be in the top 10-30%. These jobs are also harder to be replaced by NPs. Is it easier to match into the top 30% of programs (and subsequently identify a good practice niche) in psychiatry vs. say go down the path of [perhaps slightly above] average anesthesia, ophthalmology, rads or derm resident? Hard to say. Maybe yes, maybe no.

 

[Stagg737]

Why isn't it? 40% of outpatient psychiatrists are cash only. They charge anywhere between $300 an hour and $800+ an hour. MGMA median is ~300k. 90%ile would be well over 400k. You better believe people who make 400k a year are billing > $500 an hour.

Why? $400k per year working 46 weeks per year and 30 hours per week is $290/hr. Same time frame charging $500/hr is $690k gross per year. Maybe you need to charge $500/hr if you're talking about $400k take-home after taxes and overhead, but not even close to $500/hr is necessary to make $400k/yr base, even if you subtract overhead.

 

[PikminOC]

Why isn't it? 40% of outpatient psychiatrists are cash only. They charge anywhere between $300 an hour and $800+ an hour. MGMA median is ~300k. 90%ile would be well over 400k. You better believe people who make 400k a year are billing > $500 an hour.

Show me someone who is charging 800 plus an hour.

 

[PikminOC]

Why? $400k per year working 46 weeks per year and 30 hours per week is $290/hr. Same time frame charging $500/hr is $690k gross per year. Maybe you need to charge $500/hr if you're talking about $400k take-home after taxes and overhead, but not even close to $500/hr is necessary to make $400k/yr base, even if you subtract overhead.

Depends on your overhead and taxes....

 

[Psychresy]

I think the issue here is whether and when psychiatry has a competitive advantage over other specialties in time to come ("is it gonna turn into EM"). IMO there's no advantage of a run-of-the-mill psychiatry job available for a lower-tier residency grad (vs. say IM), and whatever advantage it might have now (i.e. lower workload, more time and geographical flexibility) will erode with NP infusion. The high-end jobs are often unavailable to lower-tier grads, but obviously, that's not a one to one correspondence. The high-end jobs are much more desirable than a general IM job and are comparable to the best lifestyle jobs in medicine, but you need to be in the top 10-30%. These jobs are also harder to be replaced by NPs. Is it easier to match into the top 30% of programs (and subsequently identify a good practice niche) in psychiatry vs. say go down the path of [perhaps slightly above] average anesthesia, ophthalmology, rads or derm resident? Hard to say. Maybe yes, maybe no.

What are these top tier jobs?

I'm not at a top 25 program but I go to a big University program at a school with national name recognition and some big name faculty. Are these kind of jobs available for someone like myself?

 

[dl2dp2]

What are these top tier jobs?

I'm not at a top 25 program but I go to a big University program at a school with national name recognition and some big name faculty. Are these kind of jobs available for someone like myself?

Yes. These jobs are generally not "jobs". They involve equity ownership either through starting and running your own practice, or joining and partnering at another practice. There are also facilities-based jobs, but they fall outside of a traditional academic or non-profit (i.e. private hospitals/clinics/IOPs), and also involve equity ownership.

Read the APA guide book on starting a practice:

Starting a Practice

An online reference guide for any psychiatrist thinking of starting or changing a practice.

www.psychiatry.org

Call around your area of interest and see how much other people are charging. Charge less than they do to start. Then once you are full, increase your fees. I don't know why this is all rocket science to people. All the information is literally in front of your eyes.

 

[dl2dp2]

Show me someone who is charging 800 plus an hour.

I suggest you call some medical centers in big markets (NY/LA/Bay Area/Boston/Seattle) and ask how much an eval costs from one of the faculty practice physicians. Everything I said is essentially publicly available information. Most people are just too lazy to do the leg work to get it.

 

[Psychresy]

@sluox by facilities based jobs I assume you mean for profit hospitals?

 

[Stagg737]

Depends on your overhead and taxes....

Obviously. If you're living somewhere with outrageous tax rates then finances beyond stability probably aren't a major priority for you anyway. Same for overhead, but if you're paying a significant amount there you may also just have poor business acumen.

I suggest you call some medical centers in big markets (NY/LA/Bay Area/Boston/Seattle) and ask how much an eval costs from one of the faculty practice physicians. Everything I said is essentially publicly available information. Most people are just too lazy to do the leg work to get it.

Sure, that's how much they'll charge the patient. How much of that is the psychiatrist getting though? Also, how long is allotted for those evals? $1500 for a 90 minute interview seems like it could be fairly common. But again, how much of that $900/hr is the psychiatrist actually getting?

 

[dl2dp2]

@sluox by facilities based jobs I assume you mean for profit hospitals?

To be precise, the facility-based job is a job that's based at a site that is or may become eligible to receive Medicare facilities fees, whether it is for-profit or not.

 

[dl2dp2]

Sure, that's how much they'll charge the patient. How much of that is the psychiatrist getting though? Also, how long is allotted for those evals? $1500 for a 90 minute interview seems like it could be fairly common. But again, how much of that $900/hr is the psychiatrist actually getting?

You can't keep moving the goal post. First one claims nobody is charging $800 an hour. I point to you a bunch of doctors who are charging $800 an hour, and then you say nobody can get $800 per hour in net profit, which is something I never said. To be honest I don't know how many people get $700 per hour of profit, or $600 or $300, because if you own the business the margins are meaningless except in the sense of saving payroll taxes.

MGMA gives relatively plausible figures: median ~ high 200 low 300, 90%ile would be >400k for SALARY of a W-2 job. Total income for a practice owner for top 10% would be >500k, but if you want to get there you should 1. get equity, 2. match well, 3. understand and run a business successfully.

 

[Watson & Sick]

Okay, but why is there all of this talk about midlevels threatening to replace us with no dicussion of countermeasures? It seems like everyone who believes in a bleaker future is simply resigned to it. Particularly when the general sentiment seems to be many provide substandard care.

 

[dl2dp2]

Okay, but why is there all of this talk about midlevels threatening to replace us with no dicussion of countermeasures? It seems like everyone who believes in a bleaker future is simply resigned to it. Particularly when the general sentiment seems to be many provide substandard care.

This entire thread is about countermeasures.
1. study hard, match well, work on business stuff, own equity, take control, make yourself irreplaceable to patients, and to payers

2. if you feel like group based advocacy: www.physiciansforpatientprotection.org

 

[LimpSpatula]

Okay, but why is there all of this talk about midlevels threatening to replace us with no dicussion of countermeasures? It seems like everyone who believes in a bleaker future is simply resigned to it. Particularly when the general sentiment seems to be many provide substandard care.

 

[Watson & Sick]

This entire thread is about countermeasures.
1. study hard, match well, work on business stuff, own equity, take control, make yourself irreplaceable to patients, and to payers

2. if you feel like group based advocacy: www.physiciansforpatientprotection.org

But this is the mindset that created this situation in the first place, is it not? I'm going to look out for me and as for the rest, let them eat cake.

I think if there really is a systemic problem then the only way to solve it is with a systemic, not individual, solution. If the tide is turning against many psychiatrists I think it's wishful thinking to believe it will stop just at the rung beneath you.

 

[Sushirolls]

But this is the mindset that created this situation in the first place, is it not? I'm going to look out for me and as for the rest, let them eat cake.

I think if there really is a systemic problem then the only way to solve it is with a systemic, not individual, solution. If the tide is turning against many psychiatrists I think it's wishful thinking to believe it will stop just at the rung beneath you.

Because the systemic issue also filters into the greater politic of the country left/right; conservative/liberal; academic/private; nurse/doctor; Big Box Shop/private main street, etc.

Academic, national medical societies, left leaning politicians are more apt to support nursing lobbies and perceived cost savings of midlevels with little reflection on the consequences.
-This needs to be addressed at the societal level
-This needs to be addressed at our medical society level - for instance the APA is supportive of everyone
-This needs to be addressed at the state licensure and state law level

The necessary changes are huge, and the inertia pushing in the current sad direction will be monumental to slow down.

 

[dl2dp2]

But this is the mindset that created this situation in the first place, is it not? I'm going to look out for me and as for the rest, let them eat cake.

I think if there really is a systemic problem then the only way to solve it is with a systemic, not individual, solution. If the tide is turning against many psychiatrists I think it's wishful thinking to believe it will stop just at the rung beneath you.

It may or may not be wishful thinking. I suspect the group of top 10-30% were the type who were doing psychoanalysis in the 80s and has been doing well for a long time. In some ways, these are very different "jobs" (in a broad sense) altogether: there's little in common between someone who was doing analysis on a wealthy client and someone who writes thorazine in a rural state hospital, even though they are both called "psychiatrists". Things like NP penetration (at the time it's called "managed care revolution") just don't affect the former.

You could advocate for a decrease of residency spot growth, which would have the most immediate impact, but given that you have no power in this matter I don't know how that'll help or how it'll even work. Join local APA chapters, advocate for independent private practice, site-neutral reimbursement, advocate against NPs, prescribing PhDs, etc, which many of us already do. Still, on an individual level basis, #1 is much much much more meaningful and high impact than #2.

 

[Stagg737]

You can't keep moving the goal post. First one claims nobody is charging $800 an hour. I point to you a bunch of doctors who are charging $800 an hour, and then you say nobody can get $800 per hour in net profit, which is something I never said. To be honest I don't know how many people get $700 per hour of profit, or $600 or $300, because if you own the business the margins are meaningless except in the sense of saving payroll taxes.

MGMA gives relatively plausible figures: median ~ high 200 low 300, 90%ile would be >400k for SALARY of a W-2 job. Total income for a practice owner for top 10% would be >500k, but if you want to get there you should 1. get equity, 2. match well, 3. understand and run a business successfully.

I'm not moving the goalposts. Your exact words:

Why isn't it? 40% of outpatient psychiatrists are cash only. They charge anywhere between $300 an hour and $800+ an hour. MGMA median is ~300k. 90%ile would be well over 400k. You better believe people who make 400k a year are billing > $500 an hour.

You made the claim that cash only psychiatrists are charging $800+ per hour. Then you said to call some medical centers (who almost certainly take insurance and medicare) and ask how much they charge. These are two completely different things and not really comparable. When you referred to "they charge" I was assuming a cash only practice, so net = charge before taxes and overhead anyway.

I pointed out that Charging $800+ per hour outside of a cash only private practice doesn't net $800/hr. I also pointed out that those facilities charging well over $800 for an intake are not giving the physicians large chunk of that money. Frankly, why do we care about how much is being charged? It doesn't matter if a facility charges $4,000 for an intake if the psychiatrist only sees $400 of it.

I'm aware of all of 2 psychiatrists charging that much per hour and both are in NYC. I'm sure that there's .01% of docs who are able to do this, but this is not obtainable even for most grads of elite programs.

 

[dl2dp2]

You made the claim that cash only psychiatrists are charging $800+ per hour. Then you said to call some medical centers (who almost certainly take insurance and medicare) and ask how much they charge. These are two completely different things and not really comparable. When you referred to "they charge" I was assuming a cash only practice, so net = charge before taxes and overhead anyway.

I pointed out that Charging $800+ per hour outside of a cash only private practice doesn't net $800/hr. I also pointed out that those facilities charging well over $800 for an intake are not giving the physicians large chunk of that money. Frankly, why do we care about how much is being charged? It doesn't matter if a facility charges $4,000 for an intake if the psychiatrist only sees $400 of it.

I'm aware of all of 2 psychiatrists charging that much per hour and both are in NYC. I'm sure that there's .01% of docs who are able to do this, but this is not obtainable even for most grads of elite programs.

No, actually the FPOs don't take insurance. You should just read the actual posts in this thread. Literally, the answers to your questions were already made in the previous posts. Yes, these *are* comparable services. I'm competing directly with FPO physicians of similar backgrounds but who are paid a straight salary. It's just very frustrating to go over this again and again because people lack attention to detail.

You sound like someone who never ran a practice. You should, because it'll teach you a lot. The questions you ask and the points you are making are a sign of lack of experience in this area--confusions on very basic things. I'm familiar with several markets and no it's not "0.01%" of docs. Many people are doing #VeryWell. You just don't know because you are employed by a Big Box/academic shop. Stop thinking like someone who works for a Big Box --- this style of thinking is the biggest risk for NP replacement.

 

[On Walden Pond]

be an excellent psychiatrist and you'll find good opportuity

 

[Stagg737]

No, actually the FPOs don't take insurance. You should just read the actual posts in this thread. Literally, the answers to your questions were already made in the previous posts. Yes, these *are* comparable services. I'm competing directly with FPO physicians of similar backgrounds but who are paid a straight salary. It's just very frustrating to go over this again and again because people lack attention to detail.

You sound like someone who never ran a practice. You should, because it'll teach you a lot. The questions you ask and the points you are making are a sign of lack of experience in this area--confusions on very basic things. I'm familiar with several markets and no it's not "0.01%" of docs. Many people are doing #VeryWell. You just don't know because you are employed by a Big Box/academic shop. Stop thinking like someone who works for a Big Box --- this style of thinking is the biggest risk for NP replacement.

I have been paying attention, but the numbers you're posting just aren't lining up with anything I've seen. I've never heard of a facility paying a psychiatrist an equivalent of $800/hr aside from some very niche positions. You're also correct that I'm inexperienced on the business end and have never run a practice. I did have the fortune in med school of rotating through several private practices doing very well financially where I was basically allowed to look at their books. Again, none of these charged close to $800/hr despite physicians making well over $500k/yr.

I've also only ever seen one or two employed psych jobs paying close to $800/hr and I've never heard of a salaried position in which the physician took home most of what they earned unless they owned or were partners in a practice. If you know positions where psychiatrists or even facilities are charging that much per hour and the psychiatrist actually gets to take home that amount (before taxes, overhead, etc) I'd love to see them or even know where this is and what setting they're practicing in. Feel free to DM if you don't mind sharing, because outside of a few psychiatrists for the wealthy or specific sub-specialties, taking home $800+ per hour as their regular income is something I've only heard of for an extremely limited amount of jobs.

 

[PikminOC]

I'm not moving the goalposts. Your exact words:



You made the claim that cash only psychiatrists are charging $800+ per hour. Then you said to call some medical centers (who almost certainly take insurance and medicare) and ask how much they charge. These are two completely different things and not really comparable. When you referred to "they charge" I was assuming a cash only practice, so net = charge before taxes and overhead anyway.

I pointed out that Charging $800+ per hour outside of a cash only private practice doesn't net $800/hr. I also pointed out that those facilities charging well over $800 for an intake are not giving the physicians large chunk of that money. Frankly, why do we care about how much is being charged? It doesn't matter if a facility charges $4,000 for an intake if the psychiatrist only sees $400 of it.

I'm aware of all of 2 psychiatrists charging that much per hour and both are in NYC. I'm sure that there's .01% of docs who are able to do this, but this is not obtainable even for most grads of elite programs.

Can you PM me their names?

 

[Stagg737]

Can you PM me their names?

SDN won't let me start a DM with you. I do have links though if you want to start a DM with me.

 

[tr]

Can you PM me their names?

I can PM you names and prices if you enable your PMs