For $800 an hour I'd do correctional psych at Guantanamo Bay.
Could what happened to EM happen to psychiatry?
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psychacad
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Exactly. Institutions are taking something like 50% of the cut if not more. Faculty are also not filling full time with these rates.
I also know a few PP that charge these rates but this is very rare. The majority of successful grads coming out from the top residency programs aren't charging these numbers, and there are plenty of successful non-top tier residency whatever who charge similarly.
In any case, I think people should be weary of the glorification of PP. There is a lot of shady stuff out there due to marketing pressures. The latest fad, for example, is "integrative psychiatry", where people prescribe "nutraceuticals", elimination diet, "mind body therapy" or do qEEG to "balance neural connections". Interestingly enough, most of this quackery is coming out of the top residency graduates and even faculty (google Drew Ramsey). I don't think this is the kind of psychiatry we should be encouraging.
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I'd be interested to know of this as well if it's outside of NYC. The only places I'm aware of for "gen psych" that charge over $500/hr are in NYC. Even searching the larger search engines for physicians, I found zero people charging over $500/hr outside of NYC (though I'm not that surprised by this).
psychacad
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There are in LA/SF. But once you get out of these cities, the rates drop. In SD, for example, you're looking more like $300-350/hr.
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Psychiatrists can and absolutely do charge $800+/hour. I have seen rates as high as $1,000-1,200/hour.
Are you in SD?
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Outside of NYC? I'm not saying it can't be done and I'm sure there are a few in major metros with high clusters of millionaires. If your username is accurate then your point is moot for what we're currently asking.
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Apologies. I should have been more clear. Yes, I know of colleagues in and out of NYC that charge those rates. A former colleague of mine is nowhere near New York and charges $1,000/hour.
Relatedly, I think it's important that psychiatrists start talking more about money. I find that many colleagues underestimate their worth during negotiations with hospital systems and when setting their fees in private practice.
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Do you mind PM'ing me some of the locations of those individuals and if they're practicing any sort of sub-specialty? I'm aware that some sub-specialties can charge an exorbitant amount for an appointment or some residential treatment, but outside of NYC I haven't heard of any gen-psych people who can do this. Though like I said before, I'm sure some of the cities with wealthier residents probably have some scattered here and there.
In order to charge those rates I'm assuming one needs to be in a very specific niche and in a major metro and from a top tier school?
I have no idea what I'm supposed to be worth in a potential PP. I'm coming from a mid tier University program which probably gets a boost in the public's mind given our highly ranked undergrad, law, business, etc. schools. My patients seem to like me. Aside from that there's nothing special about me. I'll be practicing in either LA or SF when I'm done. What's my worth?
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Can you tell us how much is their yearly profit? It's one thing to charge a certain amount. It's another thing to get people to pay it and to get repeat business.
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I feel like I should be concerned. How many years do you think we can keep working for decent wages and with decent geographic flexibility? I'm hoping until at least 2035 so I can have a cushiom in case I decide to walk away
If you read the EM forum they attribute the increase to corporate health entities starting EM residencies of dubious quality to flood the market with ED doctors. The increase in psych seems more related to programs actually filling, and handful of new residencies being started by passionate individuals or psych departments because there is a huge need.
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I would hardly consider an increase of nearly 35% a handful. And programs always filled, they would just have to let unmatched grads and IMGs scramble in. This is no longer the case
What will happen is that it will be even more competitive for jobs in popular areas (metropolitan areas). What we see from the increase in NPs is that they largely gravitate towards those areas. The increase in psychiatrists will also lead to more psychiatrists flocking to those areas. Good jobs will decrease as they don't have to be good and can still attract workers. If you want to do well in popular areas, you really should start a business to take advantage of the increasing supply in labor pool. It will be an uphill battle if you're one of the many looking for jobs that area.
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I don't think you'll know until you hit the job market.
I can tell you right now on the west coast I know some colleagues who have jumped from job to job annually, including in the middle of the pandemic, without much of an issue. Unclear how long that'll last.
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You have to remember these aren't really due to new residency spots that never existed in the past, but bringing back residency spots that existed in the 1990s. Because of the decline in number of people applying to psychiatry during the 90s and early 2000s many residency programs closed and number of positions contracted. That has been increasing with concomitant interest.
This data shows that by 2030, the supply of adult psychiatrists is expected to decline by 20%! Because of the ageing population of psychiatrists, the attrition rate still exceeds the number of new psychiatrists each year. On the other hand child psychiatrist positions are expected to grow by 22% such that there may be more child psychiatrists than needed by 2030. This is because the number of retirees is less than the number of new grads from child psychiatry.
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HRSA has a history of being wildly inaccurate with their estimates. Based on their predictions, which were made when there were 500 less residency spots per year than today, I should be good until at least 2030. But even their numbers for today are pretty off- if you look at their numbers for supply versus demand in, say, Mass, they say there's a surplus of hundreds of psychiatrists. And yet, I can somehow get a job anywhere in MA right now. I'm hoping there is even more of a deficit than they account for. I also don't trust their child psych numbers, since roughly half of the people I know that did child fellowships either don't work with kids at all or minimally work with children, something I don't think HRSA understands
We're still by far and away ahead of the maximum slots ever offered in the 90s, which appears to be 1,236 in 1993 before the decline. That does make overall growth look lower, however, at around 50% growth over 28 years total. That's actually much lower than most specialties overall. Kind of makes me feel better, though things may get tight as we hit the 2040s
lol...the people with the best setups are those that are good at working the system, developing contracts with cmhcs, hospital systems, and other sources of contracts. Good at organizing so they can grow the right way. They know the people to hire. Things like that....
I know plenty of psychs who make 7 figures a year. Almost all of them are FMGS. The reality is so many of these fmgs are just really driven in a business standpoint and know how to work with hospital systems, cmhcs, etc....they know how to make them happy,get the contract, and then slice and dice it.
Very little of those skills are going to be related to what medical school or residency program you went to. Once you venture outside of cash pay work, the codes all pay the same.
And even the best of the best cash pay guys cant compete with the slicers and dicers who own tons of contracts. Some dude can charge 700 dollars an hour and they aren't going to get anywhere near to the same level as a guy who is juicing from 6 large cmhcs, controls the nursing homes in the area(with one of his nps in every one lol), and has inpatient telepsych setups at a bunch of rural hospitals with midlevels in there and nice juicy stipends.
Making money in psych and being in that top percentile is all about owning equity in things, owning your own contracts,and then having other people(nps and other psychs) do the work on those contracts you have. Slice and dice baby....
For whatever reason, it seems a lot of the guys who have managed to pull this off in psych are international FMGs....good for them I guess.
It didn't take me long to figure this out....unfortunately I'm not driven enough or business saavy enough or whatever to do it....
Im sure there are niche self pay/self made positions that splik is talking about where the compensation comes out to 800 an hour. These sorts of self pay clients(either institutions or pts) do care about pedigree I'm sure. It's not my scene and I don't know much about it, but thats also a very small segment of psychiatry nationally.
But from a $ perspective, the IMGS who do it with volume volume volume volume(getting others to do the volume...but they do a lot too lol) are going to blow that out of the water.
The partners at one of the largest MH groups in the southeast are reported to make around 2.7 million per year. Not a single one has any sort of pedigree, and most are imgs. My boss is an IMG and Im sure he does way way more than that number.
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And the quality of their work tends to be not surprisingly sloppy, sloppy, sloppy, sloppy...
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I agree. Absolutely disgusting. I get my fair share of "mill" referrals and they are never, ever good.
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And whats your idea of non-disgusting, someone coming from Yale kinda thing?
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Not seeing 30+ inpatients in one day; not being the attending of record at 3+ inpatient units that you're rounding on daily; not prescribing 1-2 agents from each class of psychotropic meds just to cover patients' reported symptoms which are being taken at face value; not diagnosing every patient with vaguely sounding psychotic symptoms (regardless of context) with schizophrenia, putting them on 30mg of olanzapine and sending them on their way; not prescribing 1-2 benzos, a stimulant, and Suboxone to the same patient; not diagnosing cluster B-esq patients, likely with multiple substance use disorders, with bipolar, schizoaffective, depression, PTSD, GAD, and also have them on 3-4 agents for insomnia (my favorite combo so far, and from an MD, has been low dose mirtazapine, quetiapine, doxepin, melatonin, trazodone, and zolpidem in addition to clonazepam 2.5mg tid with a sprinkling of Adderall 45mg bid to get through the day); etc., etc.....
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psychacad
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True, but I dunno how pricing $1000 a session is supposed to be "ethically superior". In one case you're providing crappy care to many people, in the other you're excluding the large majority of the population.
As I mentioned in another thread, graduates of top programs are doing lots of shady stuff for marketing purposes in PP. Ayurveda, "integrative psychiatry", "nutraceuticals", qEEG and whatelse. Anything for marketing and none of it is evidence based.
The reality is that the $$ will likely come at the cost of care.
Just for argument sake, is excluding the vast majority from your services unethical though? Is it really comparable to providing bad care to many people?
psychacad
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Surely you'd agree that restricting access to a small slice based on class is at the least problematic, no? That's effectively what happens when the cost of care is so prohibitive.
Whenn you signed up for medicine in medical school did you sign up to be a doctor for the rich? Humanism is a fundamental value in medicine.
Same thing one could argue that the people who get crappy care wouldn't get any, otherwise.
Both practices are ethically problematic in my view. And of course the main motivation is $$, hence the problem.
Interesting discussion as this delves more into philosophy. US society has increasingly rejected one standard for truth and embraced post-modernism. How can you argue that one viewpoint is better than another viewpoint? Why shouldn't maximizing $ be the ultimate goal? Who is to say that Gordon Gekko is wrong?
Problematic yes, unethical no. To me, this is a government problem. In theory I don't think the provider should be expected to lower rates in an effort to solve the poor access problem. I feel like this mentality allows the underlying problem to be side skirted, which is that our govt won't or can't provide basic human services for all citizens.
Not being argumentative either, just enjoy the debate.
psychacad
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I think that predates postmodernism though. The identification of ethicality with profit-seeking is a fairly American idea (and one can argue has worked well in some areas, but let's just say that there's inherent tension with medicine). The other side is that class elitism is deeply entrenched. So it's a bit funny now seeing elite universities and institutions crusade from one side of their mouths about social justice and diversity in the age of woke politics, but at the same time continue to propagate elitist values and be at the complete mercy of the financial/social elite.
sure, but in the end who really cares?? You assigning yourself the title of quality police means exactly what?
I can assure you the hospitals don't care. They are happy with these arraingments because it empowers them more and gives them more options.
This thread is hilarious.....we have a bunch of people rambling on about psychs charging 1200 an hour in private practice.....as if this is anything close to the
reality in our field for 98-99% of grads. Searching around online and going to their practice websites, i searched the bay area and grads of programs like UCSF and Stanford(I'm assuming these are top places?) are more likely to charge 400-450 or so for a 1 hr appt. And it's not like they are filling up 2000 clinical hours at these rates(even if attracting patients at that rate were no issue)......
The vast majority of psychiatrists work in the settings we are all familar with- inpatient units which are obviously insurance based, community mental health centers, outpatient based practices where the psychiatrist focuses on med mgt. Then you have other areas- corrections, rehabs, a few others. But going to the outpt based practices, most are insurance based and then some are going to be self pay. Of the self pay ones, rates are generally reasonable and in the end don't match up much differently than what 3 99214s per hour would come to after accounting for the differences in pt volumes. Finally within what is already a sliver of our field(cash pay psychiatrists), there is a further tiny sliver of that which may involve these psychs catering to
people paying 1000-1200 an hour.......but speaking about them in any real sense is like speaking about a lion that chooses to play catch with zebras rather than eat them. Do a few exist out there? Sure....does that really matter or say anything about our field? No....
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People who respect professional ethics and anyone who cares about or respects psychiatry as a field. Psychiatry already has a tarnished history and sloppy, half-assed, negligent care isn't going to help that any.
sure, but you or I can't do anything about it....thats what I mean by 'who cares'.....
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I'm currently looking for a position in Michigan and possibly Ohio. There are at least 50 NP or PA psych positions for every psychiatry position.
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I’d be interested to see the 50 psych NP positions you find in Ohio for EVERY psychiatry position listed. I was also searching the same general area earlier this year and that wasn’t my experience at all.
What was your experience? What was the psych expected income?
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For the most part salary wasnt listed. It was just shocking that there are so few jobs in comparison and the AMA AOA APA is not advocating for us.
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I agree with your experience. Still, for a run-of-the-mill job, I fear that the dramatic increase of residency spots (mostly due to the opening of new programs at regional medical centers) means that the competition will get stiffer when you moved down the line, however. High-quality jobs and high compensation will not be as prevalent to lower-tier grads moving forward.
I think of SDN as sort of a harbinger. Top national university programs are not increasing spots, so I suspect that cash/"high quality" (however you define it, more competitive) institutional/facility jobs will remain not all that competitive (i.e. a name brand facility will want a staff consisting of mostly national university grads, which are of a fixed supply) IF you have the right CV. State/govt/private facilities (think HCA, etc) will have a deeper pool of new grads from a large number of places, and these grads will compete directly with PA/NPs.
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