Current Practice Environment

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F0nzie

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I wanted to share my observations regarding the current practice environment in my area. As many of you may know I have been out of residency for almost a year. I have a part-time community mh job and a private practice in one of the 10 largest cities in the US.

First observation: Psychiatric nurse practitioners out number Psychiatrists 4:1 in several of the community agencies. In a state that offers independent practice without differentiation of roles except in certain legal situations such as inpatient psychiatry this significantly reduces the number of job openings.

Second observation: 2 fresh grads from my program were laid off from a large multispecialty clinic after the outpatient psychiatry department was axed. They are back at home.

Third observation: One of the major community mh providers laid off a large number of their child psychiatrists and replaced them with psychiatric nurse practitioners.

Fourth observation: Several large multispecialty practices in pediatrics, developmental pediatrics are hiring psychiatric nurse practitioners to perform the role of a child psychiatrist and self referring.

Fifth observation: Nurse practitioners are taking an entrepreneurial role and hiring large numbers of therapists and generating internal referrals for their private practices.

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Nice going, liberal doctors! You took the bleeding heart view that patients' getting care is all that matters, thereby putting us all out of jobs. Now, let's all flee to a state that does not allow independent practice for NPs--and make hay for a few short years there until they catch up, and we have to move again...
 
Nice going, liberal doctors! You took the bleeding heart view that patients' getting care is all that matters, thereby putting us all out of jobs. Now, let's all flee to a state that does not allow independent practice for NPs--and make hay for a few short years there until they catch up, and we have to move again...

Haha, this is true in part.

I think the hardest part of this battle is that NPs simply cost less.

In a situation where there is a huge shortage and it takes a decade to train a pscyhiatrist - this scenario probably can't and won't change. To make an uneducated prediction (I feel like I have a great grasp of economics/government inclination but obviously little on the business of psychiatry), I believe this situation can only get worse.

As the Fonz is mentioning:
  • The training time for NPs is short (few years) and concentrated - minimum amount of info needed to be acceptable at the job
  • The training time for an MD/DO is long (many years/decade) and diverse - training in surgery, IM, pediatrics, OB/GYN and more
  • The government is essentially cheap and prefers to pay the least amount for healthcare services as long as they are acceptable. This is FUNDAMENTALLY different from the free market, which is fine paying double or triple for services as long as they are worth it
  • Healthcare administrators/insurance have a similar philosophy to the government
  • There is a huge shortage of psychiatrists. This is simply factual
  • The gap must be filled and there aren't enough physicians filling it - nor is the rate to fill it increasing fast enough
  • An unmet need can easily be supplied by NPs due to their ability to churn out more practioners

As trismegistus states, moving from state to state isn't a good idea - because as more and more states offer independent rights, it will become a national norm.

The challenge then lies in proving that the service a psychiatrist offers is superior to an NP. Or the challenge would be to train the psychiatrists faster. Unfortunately, the body that governs and licenses physicians moves at the pace of a snail with Parkinson's. The midlevels have that one advantage, they have determined: what's the minimum acceptable level of knowledge necessary to create a passable product? And how quickly can we pump out these degrees?

The rest is just history and letting things unfold. It's kind of scary though - seeing as the need increases less and less psychiatrists are available to fill that need, the NP will be an attractive solution to many. Especially if less psychiatrists accept insurance.
 
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Nice going, liberal doctors! You took the bleeding heart view that patients' getting care is all that matters, thereby putting us all out of jobs.
Yes, we have all been put out of jobs. Soon we won't be able to afford internet service and this forum will die out.

If you look at facts and not exaggerations, things aren't bad.
 
Good points, it's interesting and important to think about for the future of the profession and for getting patients care in a reasonable time frame. I wonder if we're headed toward a system where patients with Medicare/Medicaid/VA coverage end up seeing mostly NPs as their main provider and those with private insurance or those who pay out of pocket end up seeing mostly psychiatrists. MDs/DOs could always choose to see Medicare/Medicaid patients and see their reimbursement drop, but many will choose to fill their practices with other patients. Certainly not an ideal system but things are sort of pushing that direction. Many European countries have this sort of multi-tiered provider system so it's nothing new.
 
Good points, it's interesting and important to think about for the future of the profession and for getting patients care in a reasonable time frame. I wonder if we're headed toward a system where patients with Medicare/Medicaid/VA coverage end up seeing mostly NPs as their main provider and those with private insurance or those who pay out of pocket end up seeing mostly psychiatrists. MDs/DOs could always choose to see Medicare/Medicaid patients and see their reimbursement drop, but many will choose to fill their practices with other patients. Certainly not an ideal system but things are sort of pushing that direction. Many European countries have this sort of multi-tiered provider system so it's nothing new.

I agree this is where we are headed. The huge governing bodies will accept any product, the consumer will want the best product. Therefore only private payers or private insurance will vow for the better product.

In the end, those exceptional at their craft will be safe. The bottom feeders will suffer.
 
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And it's sort of silly to hate on midlevel providers - the government and large employers/insurers are looking to save a buck and are going to do so by any means necessary. If there were no midlevels it would just mean longer wait times for new patients, shorter/fewer appointments, less coverage and higher co-pays, and on and on.
 
I wonder if we're headed toward a system where patients with Medicare/Medicaid/VA coverage end up seeing mostly NPs as their main provider and those with private insurance or those who pay out of pocket end up seeing mostly psychiatrists. MDs/DOs could always choose to see Medicare/Medicaid patients and see their reimbursement drop, but many will choose to fill their practices with other patients.

One issue that would likely come up would be private insurers setting rates based on medicaid reimbursements (I think that is roughly the starting point for negotiations for insurers). If that is the case presumably even private insurance physicians would see a decrease in reimbursement and cash only would be the only way to avoid that.

FOnzie, do you know if psychiatrists in your area can still easily secure a job that pays reasonably or if those positions are drying up with the influx of midlevels?

Anyhow, as dim as some of these things sound in theory talking with my supervisor (who is a private practice psychiatrist) and several alums from my program who do private practice suggests that things are actually getting better in my area. With the change in billing codes it sounds like one hour patient visits with combined med management and psychotherapy are more economically viable for private insurance patients, not just cash only. I'm really not sure how things will play out but I'm still pretty optimistic that I can find a happy niche.
 
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FOnzie, do you know if psychiatrists in your area can still easily secure a job that pays reasonably or if those positions are drying up with the influx of midlevels?

I had to apply to 10 different places. I received 3 interviews and 2 of them wanted to put me through the wringer-- they were also fine with an NP taking the position. I did not have as many options as I would have liked but I am grateful to work for a company that treats me well.
 
Anyhow, as dim as some of these things sound in theory talking with my supervisor (who is a private practice psychiatrist) and several alums from my program who do private practice suggests that things are actually getting better in my area. With the change in billing codes it sounds like one hour patient visits with combined med management and psychotherapy are more economically viable for private insurance patients, not just cash only. I'm really not sure how things will play out but I'm still pretty optimistic that I can find a happy niche.

Regarding the whole insurance reimbursement change of code and add-on therapy as a game changer for outpatient psychiatry... I have my reservations. Seeing corporations larger than myself giving the chop to outpatient psychiatry due to revenue losses does not instill very much confidence in me as a solo practitioner to get paneled up and place my limited assets on the line.
 
It's very confusing to hear about the dire need for psychiatrists in many parts of the country alongside posts about how it's tough to find a job or a reasonable position out in "the real world".
 
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It's very confusing to hear about the dire need for psychiatrists in many parts of the country alongside posts about how it's tough to find a job or a reasonable position out in "the real world".

I think it goes like this:

There aren't enough to go around.

The government doesn't want to fund it very well, (less people hiring, wanting to pay less, and more likely to hire midlevels).

Areas continue to be undeserved, those with good private practices will have their plates full and those seeking employment may have to seek more due to who is hiring. Like we discussed above, the hiring will be done by larger entities which may or may not value a physician doing the work.

That's my best guess. Maybe Fonzie can tell us why he added the part time employment instead of just running the PP. Not enough pts? Benefits? What?

I do agree that it's slightly confusing because in other areas where physicians are extremely in demand, they have people head hunting them and they don't have to search for 10 offers to get 2-3 shots. They basically have people searching for them.

comments Fonz?
 
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This is a great thread!
Fonz do you know how much NP's have to pay for malpractice in your area and what standard of care they are held up to? You would be very surprised.
 
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Nice going, liberal doctors! You took the bleeding heart view that patients' getting care is all that matters, thereby putting us all out of jobs. Now, let's all flee to a state that does not allow independent practice for NPs--and make hay for a few short years there until they catch up, and we have to move again...

Wait and see if these same people will see an NP for themselves and their families when push comes to shove.
 
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I wanted to share my observations regarding the current practice environment in my area. As many of you may know I have been out of residency for almost a year. I have a part-time community mh job and a private practice in one of the 10 largest cities in the US.

First observation: Psychiatric nurse practitioners out number Psychiatrists 4:1 in several of the community agencies. In a state that offers independent practice without differentiation of roles except in certain legal situations such as inpatient psychiatry this significantly reduces the number of job openings.

Second observation: 2 fresh grads from my program were laid off from a large multispecialty clinic after the outpatient psychiatry department was axed. They are back at home.

Third observation: One of the major community mh providers laid off a large number of their child psychiatrists and replaced them with psychiatric nurse practitioners.

Fourth observation: Several large multispecialty practices in pediatrics, developmental pediatrics are hiring psychiatric nurse practitioners to perform the role of a child psychiatrist and self referring.

Fifth observation: Nurse practitioners are taking an entrepreneurial role and hiring large numbers of therapists and generating internal referrals for their private practices.

And in terms of access to care, they will take medicare/aid in their private practices.
Right.
 
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I think it goes like this:

There aren't enough to go around.

The government doesn't want to fund it very well, (less people hiring, wanting to pay less, and more likely to hire midlevels).

Areas continue to be undeserved, those with good private practices will have their plates full and those seeking employment may have to seek more due to who is hiring. Like we discussed above, the hiring will be done by larger entities which may or may not value a physician doing the work.

That's my best guess. Maybe Fonzie can tell us why he added the part time employment instead of just running the PP. Not enough pts? Benefits? What?

I do agree that it's slightly confusing because in other areas where physicians are extremely in demand, they have people head hunting them and they don't have to search for 10 offers to get 2-3 shots. They basically have people searching for them.

comments Fonz?

The following may be a bit skewed because it's based on one region of the country. I was recently looking for a new job and interviewed at places in the big city (3 million + in the metro area) all the way out to a 30,000 person town with a lonely inpatient unit. My experience echoes what others have posted on these forums. Big cities do not have a psychiatrist shortage for good jobs (child psych excluded in this statement).

The employers I met with in the big city had been interviewing several candidates over the previous month and the pay and benefits were much lower. I was clearly one of several applicants they were considering for about 180K salary job. In the smaller cities/towns, they had been advertising positions for more than 1 year, filling with locums, and couldn't get anyone to sign on despite paying significantly more (230-260K per year, base +RVU, with better reimbursement for moving, sign on, CME etc). A friend interviewed at a community mental health center in the bigger city and said he was offered 130K for full time work (30 minute follow up, 60 minute intake, with 60 minutes of charting time a day). So it's not surprising to me that Fonzie applied to 10 places and only got 2 interviews, there is much more competition in metropolitan areas.

I've also seen a lot of part-time psychiatrist mom's or dad's who are married to a spouse with a corporate job that is basically paying for everything. The psychiatrist spouse seems content to work 2 days a week and looks at their occupation less like a job and more like a hobby. Not really concerned about the paycheck. I think they may be driving the market rate for psychiatrists down in the larger markets.
 
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This is a great thread!
Fonz do you know how much NP's have to pay for malpractice in your area and what standard of care they are held up to? You would be very surprised.

Not sure about those details... It is clear, however, their scope of practice in my area is only limited by legal or forensic work.
 
Community Mental Health Centers get paid pretty well by Medicaid to the tune of $210/hr when seen by Med/Som. Doesn't matter if the Med/Som is a psychiatrist of NP. Financially it makes great sense for them to hire NPs except the whole quality thing. I inherited quite a bit of patients from a NP and I was literally speechless at some of the med mgmt decisions. Not to say there aren't good NPs out there.
 
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I inherited quite a bit of patients from a NP and I was literally speechless at some of the med mgmt decisions. Not to say there aren't good NPs out there.
True. I've had this same experience from inherited patients from other psychiatrists too...
 
Community Mental Health Centers get paid pretty well by Medicaid to the tune of $210/hr when seen by Med/Som. Doesn't matter if the Med/Som is a psychiatrist of NP. Financially it makes great sense for them to hire NPs


this.

The reality is many of us ask for 2x what psych nps get. but in *most* settings we simply aren't worth that because we don't generate 2x the revenue.
 
I wanted to share my observations regarding the current practice environment in my area. As many of you may know I have been out of residency for almost a year. I have a part-time community mh job and a private practice in one of the 10 largest cities in the US.

First observation: Psychiatric nurse practitioners out number Psychiatrists 4:1 in several of the community agencies. In a state that offers independent practice without differentiation of roles except in certain legal situations such as inpatient psychiatry this significantly reduces the number of job openings.

Second observation: 2 fresh grads from my program were laid off from a large multispecialty clinic after the outpatient psychiatry department was axed. They are back at home.

Third observation: One of the major community mh providers laid off a large number of their child psychiatrists and replaced them with psychiatric nurse practitioners.

Fourth observation: Several large multispecialty practices in pediatrics, developmental pediatrics are hiring psychiatric nurse practitioners to perform the role of a child psychiatrist and self referring.

Fifth observation: Nurse practitioners are taking an entrepreneurial role and hiring large numbers of therapists and generating internal referrals for their private practices.


agree with ALL this.

There is still some limited role for psychiatrists in public psychiatry/community mental health, but this idea that you can just go out to any and every cmhc, ask for 130/hr and set your schedule how you want it, is just not reality in most places.

I posted a cmhc job a couple months ago(where the psychiatrists were only paid like 10 bucks per hour more than psych nps which they would also take for the position) and most of the board either felt it was a troll post or some terrible isolated incident/position. The reality is that a psych np at these places who can work as efficiently as the psych(see as many pts per hour) generates just as much revenue. In other settings, I think they generate 85% of the revenue in outpt settings.

So it's not real hard to see where this will continue to go. It's only just starting guys.......
 
The following may be a bit skewed because it's based on one region of the country. I was recently looking for a new job and interviewed at places in the big city (3 million + in the metro area) all the way out to a 30,000 person town with a lonely inpatient unit. My experience echoes what others have posted on these forums. Big cities do not have a psychiatrist shortage for good jobs (child psych excluded in this statement).

The employers I met with in the big city had been interviewing several candidates over the previous month and the pay and benefits were much lower. I was clearly one of several applicants they were considering for about 180K salary job. In the smaller cities/towns, they had been advertising positions for more than 1 year, filling with locums, and couldn't get anyone to sign on despite paying significantly more (230-260K per year, base +RVU, with better reimbursement for moving, sign on, CME etc). A friend interviewed at a community mental health center in the bigger city and said he was offered 130K for full time work (30 minute follow up, 60 minute intake, with 60 minutes of charting time a day). So it's not surprising to me that Fonzie applied to 10 places and only got 2 interviews, there is much more competition in metropolitan areas.
.

what I notice though is that in more rural areas the cmhcs(at least the direct pt contact) is virtually 100% psych nps. Now if a psych really wanted to work there and have direct pt contact, they would probably let them. but my guess is the premium on what they are going to pay relative to the psych nps(who know basically nothing if just out of their 'training') is maybe 10%.
 
Wait and see if these same people will see an NP for themselves and their families when push comes to shove.

this isn't a subdural hematoma grover. These are community med mgt pts who don't have a lot of access and are going to take what they get. They aren't generally all up in arms when they see a psych np, a psychologist, a sw, or a psychiatrist. They just want to be treated fairly, processed through the system as efficiently as possible, get a case manager to help them out with the things that really concern them, etc......

many of these patients in these settings don't even know who is a psychiatrist and who isn't. And the ones that do mostly don't care.
 
So... Psychiatry is the new Anesthesiology?


gosh no....we wish. Anesthesia, for all the doom and gloom posts, still makes tons of $$ off the ACT model. The great majority of crnas in this country are making money FOR anesthesiologists. The great majority of psych nps are NOT making money for us. And I don't see either of those things changing.
 
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Regarding the whole insurance reimbursement change of code and add-on therapy as a game changer for outpatient psychiatry... I have my reservations. Seeing corporations larger than myself giving the chop to outpatient psychiatry due to revenue losses does not instill very much confidence in me as a solo practitioner to get paneled up and place my limited assets on the line.

almost every single person I've talked to in private practice states the code changes have hurt revenue overall. The idea that changes in the way things are coded are going to help the little guys(ie us) as opposed to the powerful people is laughable. That's not how the real world works.
 
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almost every single person I've talked to in private practice states the code changes have hurt revenue overall. The idea that changes in the way things are coded are going to help the little guys(ie us) as opposed to the powerful people is laughable. That's not how the real world works.
I was invited to join a PP model but the coding purely sucks and reimbursements are just not there.
 
I was invited to join a PP model but the coding purely sucks and reimbursements are just not there.

agreed......I do think that the best jobs out there right now(from a compensation-workload-pace standpoint) are at VAs. You won't make much money(especially if that is your only job), but at many VAs the pace is laid back, the stress is low, and the hours are good.

I think in 10 years though even that model will be affected and go downhill. We already know that the VA is hiring large numbers of psych nps to do their own outpt stuff. That's only going to continue to increase.
 
agreed......I do think that the best jobs out there right now(from a compensation-workload-pace standpoint) are at VAs. You won't make much money(especially if that is your only job), but at many VAs the pace is laid back, the stress is low, and the hours are good.

I think in 10 years though even that model will be affected and go downhill. We already know that the VA is hiring large numbers of psych nps to do their own outpt stuff. That's only going to continue to increase.

I'm at the VA now. It's not a good place because bureaucracy rules rather than good Vet care. Also, you'll get pulled to cover stuff you didn't agree to when you signed on the dotted line. However, I feel at more ease and less pressure because I do have more time to see them and can spend an hour if needed. Productivity be damned in my book... No lost Patients/No one left behind.
 
However, I feel at more ease and less pressure because I do have more time to see them and can spend an hour if needed. Productivity be damned in my book... No lost Patients/No one left behind.
The left behind patients are the ones waiting six months for an appointment because productivity has been damned. I have a lot of love for the VA, but this is the main complaint vets have about the system, and it's a righteous one.

I see the logic of spending as much time as you'd like with a patient, and it's very satisfying, but pretending it doesn't come at a cost does a disservice to the veterans.
 
So this thread has thoroughly depressed me. So what do we do? I started a thread about this a while ago -- my state's psychiatric association has a measure to pretty much exclude psych NPs from the association and strictly define psychiatric providers as MDs/DOs. They also lost a big fight last year when the our state legislature passed a bill mandating insurers pay midlevels the same as physicians in psychiatry and primary care, which I think is the push behind this name change. Personally, I think it makes us seem like elitist jerks in the public perception and won't go over well. If you've been paying attention at all to mainstream media articles, you'll see that midlevels (especially NPs) are doing a way better job than us at advocating their position.

So who is our voice? What's our message? How do we frame it in a way that will appeal to those folks who already think we're people who make too much money as it is? Relying on information about our extended years of training doesn't cut it -- we've already tried that, and it's not working.
 
So this thread has thoroughly depressed me. So what do we do? I started a thread about this a while ago -- my state's psychiatric association has a measure to pretty much exclude psych NPs from the association and strictly define psychiatric providers as MDs/DOs. They also lost a big fight last year when the our state legislature passed a bill mandating insurers pay midlevels the same as physicians in psychiatry and primary care, which I think is the push behind this name change. Personally, I think it makes us seem like elitist jerks in the public perception and won't go over well. If you've been paying attention at all to mainstream media articles, you'll see that midlevels (especially NPs) are doing a way better job than us at advocating their position.

So who is our voice? What's our message? How do we frame it in a way that will appeal to those folks who already think we're people who make too much money as it is? Relying on information about our extended years of training doesn't cut it -- we've already tried that, and it's not working.

this issue has many layers:

1) for starters, we need to understand that our plight and issues being in mental health care is NOT the same as all other practitioners and midlevel encroachment. I see a lot of comments about anesthesiologists and obgyn and whatnot.....totally different. Even outpt primary care(which we have more similarity with) has different issues than us. Most physicians will continue to profit off of midlevels. A dermatologist who employs 2 midlevels has ZERO in common with us.

2) you are totally on the spot when you say relying on our years of training and med school doesn't cut it. NOBODY CARES. All the matters are outcomes, and the bottom line. We do something, especially in an outpt setting, where outcomes and especially very bad ones are hard to tease out. There are a lot of terrible psych nps sure, but we all know that there are a lot of terrible psychiatrists out there as well.

3) I don't think there is much we can do. One thing I'm working on is accepting things the way they are. Things aren't that bad when looking at the big picture. yes, I won't make a lot of money. Life goes on.....
 
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The left behind patients are the ones waiting six months for an appointment because productivity has been damned. I have a lot of love for the VA, but this is the main complaint vets have about the system, and it's a righteous one.

I see the logic of spending as much time as you'd like with a patient, and it's very satisfying, but pretending it doesn't come at a cost does a disservice to the veterans.

I think it's also important to look at why productivity has been damned at the VA.....I don't think it's because VA administators are saying "we're only going to have our psychs see x number of patients per week because we want to make sure that our psychs are able to provide patient centered care to every veteran". The reality is productivity has been damned at the VA for the same reasons it has also been damned at the county car tag office and drivers licence office....it's just the inefficiencies of such govt offices. Now is that a fortunate thing for those psychs who like to work at that pace? Sure. but it's not like the psychs there are providing holistic care...their model isn't all that much different than high volume outpt pp. Same model(everyone still gets referred to an lcsw for example) but without the volume.

I wish I could tolerate working at the VA because I'd make a good bit more money(155ish as opposed to 95ish), but I just can't.
 
I think it's also important to look at why productivity has been damned at the VA.....I don't think it's because VA administators are saying "we're only going to have our psychs see x number of patients per week because we want to make sure that our psychs are able to provide patient centered care to every veteran". The reality is productivity has been damned at the VA for the same reasons it has also been damned at the county car tag office and drivers licence office....it's just the inefficiencies of such govt offices. Now is that a fortunate thing for those psychs who like to work at that pace? Sure. but it's not like the psychs there are providing holistic care...their model isn't all that much different than high volume outpt pp. Same model(everyone still gets referred to an lcsw for example) but without the volume.

I wish I could tolerate working at the VA because I'd make a good bit more money(155ish as opposed to 95ish), but I just can't.

VISTARIL, do us all a favor and just get out of Psychiatry and do something else. There are plenty of ways to make money in this field and the new coding changes are at worst not an improvement and at best a significant improvement from the old codes. 95ish? Are you kidding me? I'm a fellow and I pulled in 140K in my 4th year of residency and will pull slightly more as a fellow with moonlighting. I plan on making significantly more than that during my career. Just be ready to work hard.
 
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What about the Kaiser system in states like California where they have so much market share and are physician run? Because I really need the market's bottom to hold for at least 10 more years. Otherwise I'm F'd! I don't have the luxury of these low figures I'm seeing in this thread.

What States are still holding the line against the NP assault?

What about forensic units and state hospitals? Or prisons?
 
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The left behind patients are the ones waiting six months for an appointment because productivity has been damned. I have a lot of love for the VA, but this is the main complaint vets have about the system, and it's a righteous one.

I see the logic of spending as much time as you'd like with a patient, and it's very satisfying, but pretending it doesn't come at a cost does a disservice to the veterans.

Well, I agree on one level - slower times means less service. But at the same time, hard to blame the psychiatrist. At some point you can't continue to speed up care - quality eventually will suffer. But again, your point is well taken.
 
VISTARIL, do us all a favor and just get out of Psychiatry and do something else. There are plenty of ways to make money in this field and the new coding changes are at worst not an improvement and at best a significant improvement from the old codes. 95ish? Are you kidding me? I'm a fellow and I pulled in 140K in my 4th year of residency and will pull slightly more as a fellow with moonlighting. I plan on making significantly more than that during my career. Just be ready to work hard.

Dude.

How have you not put him on ignore yet. It's been among one of the best decisions I've made in my life.

Sometimes I forget to log in and I read a post by a grumpy malignant chap waxing poetic about his tribulations of having only 2 physician incomes in his household and how hospitalists earn 500k and neurosurgeons earn 1 million dollars with the ease of stealing candy from a baby.

At this point I quickly sign in before my mind is polluted further!
 
I'm not a fan of professional masochism either, IAP, but this thread was started by Fonzie--somebody who has been consistently educational about the psychiatry workplace.

Further, there is an undeniable economic common sense at work that is impossible for us to ignore. Even if you rule out the extreme end that V represents you still have to acknowledge the point being made. I, for one, don't know enough to say anything about the job market for new grads.
 
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Vistaril made some good points here, in my opinion. Most patients really do not care to hear about our years of training and experience. They want outcomes, results, and they want to see a provider now and not in 6 months. They want to feel better. If an NP can see them next week and give them the same medication and refer them to the same LCSW as the psychiatrist next door, why do they care? I think we have to be realistic.

Also, Vistaril is right that we need to take a step back and look at the big picture. Look at the work teachers do and the incredibly valuable services that your average social worker provides. Now look at their reimbursement and job prospects. We went into medicine for a reason, and that reason is hopefully good patient care. We will have jobs, we will pay back our loans, we will have a decent place to live and food to eat. The sky is not falling. And it's not the NPs fault, the entire system is getting crunched and we are just getting started. Life goes on.
 
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Reading this thread reminds me of the US auto industry back in the 70s and 80s whining about how unpatriotic people were for not "Buying American", when 'American' meant 'boxy hunk of steel that got 8 MPG and rusted out in 3 years, but had a nice roomy interior'.
 
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I'm not a fan of professional masochism either, IAP, but this thread was started by Fonzie--somebody who has been consistently educational about the psychiatry workplace.

Further, there is an undeniable economic common sense at work that is impossible for us to ignore. Even if you rule out the extreme end that V represents you still have to acknowledge the point being made. I, for one, don't know enough to say anything about the job market for new grads.


I don't know Fonzie personally but from a previous posting of his I know what metro area he is referring to. I actually will be relocating to this same metro area from the East Coast soon and will be starting my own addiction clinic based on successful (quickly expanding) models I have seen in the East coast city I currently live in. Also affecting the metro area Fonzie lives in is that a major hospital system attempted to force all their inpatient psychiatrists to sign non-compete clauses causing a mass exodus of inpatient psychiatrists (at least 10) to other systems. So, in combination with independent NP's taking over CMHC's, this could also be playing a roll in the local job market for psychiatrists. I did interview at that same hospital system (which drove a lot of psychiatrists out) and they are absolutely desperate to hire inpatient psychiatrists and are offering ~230K base with additional income tied to RVU production (of course you have to sign a non-compete).
 
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One other quick note about geographic-dependent issues, I've spoken to many rural physicians, both psychiatrists and others, and if you are willing to live in a less populated area of the country, even if it's not completely rural, you are going to have some amazing opportunities. The door is wide open for physicians in these underserved areas, and will remain open for the foreseeable future. NPs tend to shy away from these areas just as much as physicians.
 
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Vistaril made some good points here, in my opinion. Most patients really do not care to hear about our years of training and experience. They want outcomes, results, and they want to see a provider now and not in 6 months. They want to feel better. If an NP can see them next week and give them the same medication and refer them to the same LCSW as the psychiatrist next door, why do they care? I think we have to be realistic.

Also, Vistaril is right that we need to take a step back and look at the big picture. Look at the work teachers do and the incredibly valuable services that your average social worker provides. Now look at their reimbursement and job prospects. We went into medicine for a reason, and that reason is hopefully good patient care. We will have jobs, we will pay back our loans, we will have a decent place to live and food to eat. The sky is not falling. And it's not the NPs fault, the entire system is getting crunched and we are just getting started. Life goes on.

Although I can't read V's posts, I've heard the arguments before. I have a fundamentally different philosophy.

V's argument goes like this: Patients don't care about quality, they want outcomes. If an NP can Rx a drug, set up an appt and do all that for cheaper than a doctor - then where does the physicians value come in? Why train so long for such a simple job? Writing Rx for simple Dx and setting up further appointments?

My counter argument would be, there are people who WILL and DO pay more for higher quality services. This can be seen in any industry in the world. If the patient sees value in what they pay for, they will buy it.

What is the added value? If a psychiatrist is exceptional at what they do, exceptional with communication, therapy, knowledge base, knowing other medical problems that present like psychiatric problems, exceptional at marketing and networking, and caring for the patients - then this individual WILL have plenty of patients vying to use their services for a lifetime. How much more would they pay compared to an NP? Well, it depends on their income.

In a doomsday scenario that NPs are nationally accepted to practice like an MD, I would not fear. My strategy? I will just market myself to individuals earning 100k -500k or more. If the government forces me to have a practice that is not viable to the general public, I can play that game. In fact, I think my earnings would increase in this doomsday scenario. That's business and marketing, networking. Do you think a single guy earning 300k cares if he pays $100 or $200 for psych? Nope. He wants a quality product.

What we are venturing into is like evolution or computer hacking. Throughout the millions of years of evolution, certain changes forced the organisms that could thrive to adapt and become better. The organisms that adapted reached new levels of performance. In computer hacking, every time a new security update is made there is a hacker somewhere trying to break it - and they do. They find the way in.

Welcome to the game of life.

If everything goes wrong, I don't know what the solution is yet. But I do know the sure way to failure. Believe and tell everyone that your extra training has no value, that all you do is Rx drugs and that there is no reason for your job if plenty of NPs come along. That's an attitude that's sure to land you in the bottom 10%'tile in earnings.

In summary: V thinks so little of what he does, I on the other hand think so highly of what a psychiatrist can do.
 
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What about the Kaiser system in states like California where they have so much market share and are physician run?
At Kaiser, you will be doing STRICTLY short medication management visits. Psychiatrists do not do standalone therapy.
 
At Kaiser, you will be doing STRICTLY short medication management visits. Psychiatrists do not do standalone therapy.

It seems like Kaiser is the place that's hiring the most around here, and this right here seems like the biggest downside. Also, I think they're pretty busy. However, here, it's a 4 day a week schedule with good (depending on how you define that) pay and really good benefits (like 20% in retirement type of stuff). I'm not entirely sure I wouldn't do it, but the no therapy thing is pretty huge. Also, they don't allow you to have your own practice on the side.

Regarding work in general, my classmates looking for jobs haven't had a hard time finding something.

Editing to add that in general, I think the thing we can really offer as mental health professionals is the ability to listen to our patients and conceptualize them as humans, not as diagnostic categories and not as people who need to adhere to one strict treatment box. My thought is that if you do that, you will find people who are willing to make sacrifices to see you because you don't get that from most mental health care given in larger systems.
 
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Although I can't read V's posts, I've heard the arguments before. I have a fundamentally different philosophy.

V's argument goes like this: Patients don't care about quality, they want outcomes. If an NP can Rx a drug, set up an appt and do all that for cheaper than a doctor - then where does the physicians value come in? Why train so long for such a simple job? Writing Rx for simple Dx and setting up further appointments?

My counter argument would be, there are people who WILL and DO pay more for higher quality services. This can be seen in any industry in the world. If the patient sees value in what they pay for, they will buy it.

What is the added value? If a psychiatrist is exceptional at what they do, exceptional with communication, therapy, knowledge base, knowing other medical problems that present like psychiatric problems, exceptional at marketing and networking, and caring for the patients - then this individual WILL have plenty of patients vying to use their services for a lifetime. How much more would they pay compared to an NP? Well, it depends on their income.

In a doomsday scenario that NPs are nationally accepted to practice like an MD, I would not fear. My strategy? I will just market myself to individuals earning 100k -500k or more. If the government forces me to have a practice that is not viable to the general public, I can play that game. In fact, I think my earnings would increase in this doomsday scenario. That's business and marketing, networking. Do you think a single guy earning 300k cares if he pays $100 or $200 for psych? Nope. He wants a quality product.

What we are venturing into is like evolution or computer hacking. Throughout the millions of years of evolution, certain changes forced the organisms that could thrive to adapt and become better. The organisms that adapted reached new levels of performance. In computer hacking, every time a new security update is made there is a hacker somewhere trying to break it - and they do. They find the way in.

Welcome to the game of life.

If everything goes wrong, I don't know what the solution is yet. But I do know the sure way to failure. Believe and tell everyone that your extra training has no value, that all you do is Rx drugs and that there is no reason for your job if plenty of NPs come along. That's an attitude that's sure to land you in the bottom 10%'tile in earnings.

In summary: V thinks so little of what he does, I on the other hand think so highly of what a psychiatrist can do.

I don't neccessarily disagree with a lot of what you wrote. My point has always been that there just aren't enough patients willing to pay for that premium level of service. Patients with Schizophrenia, Schizoaffective disorder, and most bipolar patients do not typically have the 300k incomes you mention. There are small pockets of anxiety d/o and some depression patients who do, and within these pockets some(but certainly NOT all and I would argue not even most) are willing to pay premium prices. For the psychiatrists out there(and especially junior residents and medical students who constantly post about this niche market and how easy it is), great.....go for it. Your skill set is a lot better than mine then.
 
One other quick note about geographic-dependent issues, I've spoken to many rural physicians, both psychiatrists and others, and if you are willing to live in a less populated area of the country, even if it's not completely rural, you are going to have some amazing opportunities. The door is wide open for physicians in these underserved areas, and will remain open for the foreseeable future. NPs tend to shy away from these areas just as much as physicians.

It really depends on what amazing means.....it is much easier to get a job period, but in these areas the work tends to have less variety. The appts will tend to be shorter(or higher volume number of inpatients) and it's likely to be a situation where volume is even more emphasized. Also the cash pay model many people around here are in love with is practically unheard of in these areas.
 
Reading this thread reminds me of the US auto industry back in the 70s and 80s whining about how unpatriotic people were for not "Buying American", when 'American' meant 'boxy hunk of steel that got 8 MPG and rusted out in 3 years, but had a nice roomy interior'.

In this analogy wouldn't you be the plant director at a factory making those underperforming cars?

What needs to change in psychiatric training to get us to where I don't have to worry about a nurse eating my lunch?
 
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