Do psychiatrist start concierge style practices?

[carlosc1dbz]

I was curious about this topic since yesterday so I thought I would see what you guys have to say. Along with the concierge style practice I also now that many physicians in private practice are starting to do some cosmetic stuff for patients, example botox shots. I understand it to be a good way to plump up ones income. Do psychiatrist do anything of this sort to increase their earning potential?

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[michaelrack]

many psychiatrists don't take insurance

 

[carlosc1dbz]

many psychiatrists don't take insurance

How does one make the move from taking insurance to cash only? Is it a gradual move?

 

[rama kandra]

I am wondering what concierge practice means but I assume you are talking about something along the lines of a private practice, boutique service type idea where you offer multiple services and usually high end. You can do that and I am putting together some business ideas for the practice I would like to do in the future. This depends on where you live and what the area supports in terms of psychiatrists. Those who lack any idea would say 'nyc' or some big metro center as the ideal - they are wrong.

These places are saturated with 700 dollar an hour celebrity type psychiatrists and will not be deterred by your entrance. You would have to work in a lower income, less psychiatrist-dense population and build a very strong base of patients and reputation before you can consider going toward a cash business. I work in a psychiatry practice in the burbs and there is no chance we can really go into cash in spite of a moderately wealthy town - it just isn't going to work easily. Transitioning to cash practice sometimes means you have a less opportune patient schedule and basically your reputation is everything you can hinge on - nobody will get you patients since you arn't taking insurance which provides your name.

Second, a boutique firm like anything else requires a unique service and that means costs. You wont stop rich people from going into your practice unless it beats their multi-million dollar service that they are used to. Consider these points in your time before planning the dream practice.

 

[carlosc1dbz]

I am wondering what concierge practice means but I assume you are talking about something along the lines of a private practice, boutique service type idea where you offer multiple services and usually high end. You can do that and I am putting together some business ideas for the practice I would like to do in the future. This depends on where you live and what the area supports in terms of psychiatrists. Those who lack any idea would say 'nyc' or some big metro center as the ideal - they are wrong.

These places are saturated with 700 dollar an hour celebrity type psychiatrists and will not be deterred by your entrance. You would have to work in a lower income, less psychiatrist-dense population and build a very strong base of patients and reputation before you can consider going toward a cash business. I work in a psychiatry practice in the burbs and there is no chance we can really go into cash in spite of a moderately wealthy town - it just isn't going to work easily. Transitioning to cash practice sometimes means you have a less opportune patient schedule and basically your reputation is everything you can hinge on - nobody will get you patients since you arn't taking insurance which provides your name.

Second, a boutique firm like anything else requires a unique service and that means costs. You wont stop rich people from going into your practice unless it beats their multi-million dollar service that they are used to. Consider these points in your time before planning the dream practice.

Amazing insight. I am thinking that I have nothing to offer yet since Im still in medical school, but my plan is to make some public appearances as well as do some tv show appearances that are constant as well as some radio show appearances. That would work I think if I wanted to go mainstream, but in a large city like LA or something. Just saying.

 

[OldPsychDoc]

Amazing insight. I am thinking that I have nothing to offer yet since Im still in medical school, but my plan is to make some public appearances as well as do some tv show appearances that are constant as well as some radio show appearances. That would work I think if I wanted to go mainstream, but in a large city like LA or something. Just saying.

So, I'm just starting to wonder...are you interested in actually working with mentally ill patients? Or is it just that you like the idea of "being a psychiatrist", maybe making some money off of that identity?

 

[rama kandra]

A lot of the ways doctors are used to working will change in the future - they will have to be more aggressive about how they run their practices and jobs. They will need to be more familiar with business ideas and managing a business. Lord knows how many stereotypes we have about doctors as investors - but the fact remains that we have a paradigm shift in American medicine.

To complain about it is ignorant and to react to it favorably is the better way. If you want to run a practice outside of the insurance complex, you will have to be a better writer, a better salesman for your services. Don't stoop to the level of newspaper ads but consider a doctor who treated Frank Gehry for decades as his therapist - they did a documentary film about the relationship. Another doctor I know of, was Steven Colberts orthopedist during his broken arm period - and the guy was a DO and went on the show a few times to discuss the procedure (and removed the cast, it was hilarious) but i am sure he used it pretty much all over his website and got patients.

Then you can just spend your time writing popular pieces about your profession in general, like Atul Gawande does in the new yorker. I am certain he gets a lot of publicity today and patients want his services if they need them. Also look to the famed surgeons of new york and the big name hollywood plastics guys. Some are doing very well in their field.

Just dont go into gimmicks. Offer a full package mental health clinic and it usually works itself out in your favor.

 

[OldPsychDoc]

A lot of the ways doctors are used to working will change in the future - they will have to be more aggressive about how they run their practices and jobs. They will need to be more familiar with business ideas and managing a business. Lord knows how many stereotypes we have about doctors as investors - but the fact remains that we have a paradigm shift in American medicine.

To complain about it is ignorant and to react to it favorably is the better way. If you want to run a practice outside of the insurance complex, you will have to be a better writer, a better salesman for your services. Don't stoop to the level of newspaper ads but consider a doctor who treated Frank Gehry for decades as his therapist - they did a documentary film about the relationship. Another doctor I know of, was Steven Colberts orthopedist during his broken arm period - and the guy was a DO and went on the show a few times to discuss the procedure (and removed the cast, it was hilarious) but i am sure he used it pretty much all over his website and got patients.

Then you can just spend your time writing popular pieces about your profession in general, like Atul Gawande does in the new yorker. I am certain he gets a lot of publicity today and patients want his services if they need them. Also look to the famed surgeons of new york and the big name hollywood plastics guys. Some are doing very well in their field.

Just dont go into gimmicks. Offer a full package mental health clinic and it usually works itself out in your favor.

The question remains: Do you actually want to work with mentally ill patients?

 

[rama kandra]

Why do you care to hear me say what you know will be a victory for you: no, I don't WANT to practice with severe cases. I know that mental illness is treated more commonly in hospitals and city university places while a private practice supplements the population that is less severe. What is wrong with this assessment? My interests are not to work in a hospital, or to treat the cases which I am less inclined to want. I am providing a service, and know it will be my own choice.

On the end all we have left is our own choice, if it isn't handed to us by someone else. Who I chose to work for and what my reasons are should not be anybody's concern unless I break the law or do not treat my patients, neither of which I plan on doing.

Best of luck to you though.

 

[dl2dp2]

To the OP:

To charge $500-$800 in a metro for rich clients remains a very very competitive proposal. Yes, you can do this in psychiatry, but to best position yourself like this probably involves matching into the most competitive 5-10 residency programs (if not the top 5), do very very well clinically, get hooked up to the most prestigious practice groups in the city, being able to develop a client base through networking and socializing with the "elite". Another common pathway is to becoming administrative and academically active--rich people want to be treated by "the world expert" in something or a department chair. And this involves running large multicenter trials, being PIs on prestigious projects, etc., but then this interferes with your cash raking clinical schedule--meaning you can only charge $500 for a few hours a week while being mired in your research and administrative career. The department chairman at Einstein, as reported by NYTimes a while ago, charges $800 an hour. NYU child study center, in no way a "concierge practice", as another example, explicitly does not take insurance, and can theoretically charge up to $3000 per evaluation session. Of course, a lot of this goes to ancillary support.

If you want to cater to rich people, you need to know what they want. How many investment bankers do you REALLY know? How many billionaires? How many movie stars? And these department chairmen and superstar researchers REALLY know them--they have to go to fundraisers. They have relationships developed since private prep school, etc. etc. Their social circles OFTEN intersect. You need to suck it up and deal with that. Sadly for you, the most prestigious programs are not looking for people who are interested in building a high-end boutique practice at all. So you have to "lie" your way into one. How long are you going to lie to yourself being a psychiatrist before everything crashes down on your conscience and you have a severe major depressive episode? Things to consider...

If you are looking for a stable and easy way to make neurosurgery salary in psychiatry, it simply does not exist. However, hopefully you have realized at this point that for the most part psychiatrists don't work as hard. There are lots and lots of med managements to be seen for $86 per 15-min Medicare, and most psychiatrists do ok in the end with this "non-concierge style" life. There is no free lunch. If you want to be really filthy rich working 30 hrs a week, chances are you have to work for a long time to get to that point, and there is no recipe. why not just work hard in med school and go into derm instead?

 

[billypilgrim37]

Why do you care to hear me say what you know will be a victory for you: no, I don't WANT to practice with severe cases.

I am going to put words in OPD's mouth, because from past correspondences, I think our political biases overlap about 98%.

As commie pinko midwestern democrats, we see psychiatry as an opportunity to serve the most marginalized members of society who suffer from severe mental illness. Psychiatry that is not in the trenches does much less to help the marginalized than psychiatry that is in the trenches. For every person who takes a psychiatry slot who plans to offer some sort of fluffy psychiatric practice to upper middle class and higher clientele, there is one less psychiatrist available to treat the severely mentally ill. So, people with your agenda directly interfere with our agenda.

This isn't the view of the vast majority of psychiatrists, and given the slant on this board is actually substantially to the right the psychiatric community at large, I'm guessing that only OPD and maybe a few other people will be sympathetic to this paradigm. Others will argue that the slot and what you choose to do with it is your business, and I should go @#$^ myself if I think otherwise. That's fine. I've never claimed to be a libertarian.

I'm not saying people with our agenda are saints or any crap like that. If we wanted to, we could work 100 hours a week for free, but we don't do that. But people who see psychiatry as a "business opportunity" are always going to get on the nerves of those of us who see psychiatry as "an opportunity to do some good for the marginalized of society while getting paid enough to live very comfortably."

 

[OldPsychDoc]

I am going to put words in OPD's mouth, because from past correspondences, I think our political biases overlap about 98%.

As commie pinko midwestern democrats, we see psychiatry as an opportunity to serve the most marginalized members of society who suffer from severe mental illness. Psychiatry that is not in the trenches does much less to help the marginalized than psychiatry that is in the trenches. For every person who takes a psychiatry slot who plans to offer some sort of fluffy psychiatric practice to upper middle class and higher clientele, there is one less psychiatrist available to treat the severely mentally ill. So, people with your agenda directly interfere with our agenda.

This isn't the view of the vast majority of psychiatrists, and given the slant on this board is actually substantially to the right the psychiatric community at large, I'm guessing that only OPD and maybe a few other people will be sympathetic to this paradigm. Others will argue that the slot and what you choose to do with it is your business, and I should go @#$^ myself if I think otherwise. That's fine. I've never claimed to be a libertarian.

I'm not saying people with our agenda are saints or any crap like that. If we wanted to, we could work 100 hours a week for free, but we don't do that. But people who see psychiatry as a "business opportunity" are always going to get on the nerves of those of us who see psychiatry as "an opportunity to do some good for the marginalized of society while getting paid enough to live very comfortably."

Though I am indeed a "commie pinko midwestern democrat" (and fully expecting to be assigned to a re-education camp in Montana once the coming Palin-Bachmann administration takes over), my main issue in questioning carlos' and rama's desire to work with the mentally ill actually has more to do with their happiness than with keeping psychiatry safe for liberals.

As someone regularly interviewing candidates for psychiatric residency, I can't help but feel that you are likely to be miserable as a medical student and resident if you are just putting up with this population in order to get credentialled to run your business/practice as you see fit. I make a nice income for my family, and I am not apologetic for it, nor do I live in a cardboard box to display solidarity for my clients--but if I don't love, or at least really really really LIKE what I'm doing each day, I'm not going to get out of my cozy midwestern commie-pinko bed in the morning.

(Was that 98% in concordance, billy?)

 

[billypilgrim37]

Was that 98% in concordance, billy?

👍

 

[surftheiop]

Best of luck to you though.

Ugh can you take your condescending remarks back to the pre-med MCAT forum where you so loved playing the role of "insightful psychiatrist wannabe"? I expect that stuff there, but I enjoy just sitting back and reading what the real docs have to offer here.

 

[abcxyz0123]

my main issue in questioning carlos' and rama's desire to work with the mentally ill actually has more to do with their happiness than with keeping psychiatry safe for liberals.

but if I don't love, or at least really really really LIKE what I'm doing each day, I'm not going to get out of my cozy midwestern commie-pinko bed in the morning.

(Was that 98% in concordance, billy?)

who says he wouldnt be happy? "selling out" in psychiatry (or any field in medicine) and happiness are not mutually exclusive.

 

[carlosc1dbz]

Why do you care to hear me say what you know will be a victory for you: no, I don't WANT to practice with severe cases. I know that mental illness is treated more commonly in hospitals and city university places while a private practice supplements the population that is less severe. What is wrong with this assessment? My interests are not to work in a hospital, or to treat the cases which I am less inclined to want. I am providing a service, and know it will be my own choice.

On the end all we have left is our own choice, if it isn't handed to us by someone else. Who I chose to work for and what my reasons are should not be anybody's concern unless I break the law or do not treat my patients, neither of which I plan on doing.

Best of luck to you though.

As long as you are helping people live a better quality of life, then more power to you. There is no need to judge people based on what their objectives are, as long as they are caring for people and helping them with their mental health needs. Yeah you can argue all the altruism that you want and how only pure intentions will allow you to successfully treat someone, but most people would agree it is not a prerequisite for successful treatment. People can argue that you are going to be miserable and blah blah blah, but in the end other people do not decide what makes YOU happy.

I think it is great that you are honest about your goals, for it would be far worse if you were pretending to want to work in a hospital or taking care of cases you did not want to deal with.

 

[carlosc1dbz]

So, I'm just starting to wonder...are you interested in actually working with mentally ill patients? Or is it just that you like the idea of "being a psychiatrist", maybe making some money off of that identity?

Why cant you like both, geez.

 

[OldPsychDoc]

Why cant you like both, geez.

Because in my experience, if you don't intrinsically enjoy this stuff, you will not make it to the point in your career where the extrinsic rewards of prestige and relative riches kick in.

 

[rama kandra]

All valid points, well taken. I was not trying to be condescending and realize I ought to stick to pre-allo forums since I have nowhere near the experience of the medical doctors and residents who are here. I'm glad you have a strong desire to defend what you do and at the least, OldPsychDoc lives pretty well and thats all I ask of doctors in general - do your job but don't take your skills and knowledge as something to be given away for less. Too much of medicine is being marginalized and doctors take less growth in their salary which I don't agree with.

As a result I would not disagree that I could wind up quite unhappy but that is a risk that everybody takes in medicine. How many folks going to med school really have a clue? The truth is we sometimes find out in hindsight about whether this is the best for us. Let us disagree on the outcome but I think I still have my heart in this career and to make the most of it. Can anyone really deny that we have such different ideals? I think we have a lot in common.

As for stealing someones spot for taking care of marginalized people - I ask that why do we assume that our job is to take care of marginalized over the less marginalized? That is an assumption you make about your career in general and more specifically does not seem to make sense because hospitals close down as a result of taking non paying clients which is not just a philosophical matter as much as a practical one. If we took care of marginalized patients would the medical complex even function?

 

[Sneezing]

I am going to put words in OPD's mouth, because from past correspondences, I think our political biases overlap about 98%.

As commie pinko midwestern democrats, we see psychiatry as an opportunity to serve the most marginalized members of society who suffer from severe mental illness. Psychiatry that is not in the trenches does much less to help the marginalized than psychiatry that is in the trenches. For every person who takes a psychiatry slot who plans to offer some sort of fluffy psychiatric practice to upper middle class and higher clientele, there is one less psychiatrist available to treat the severely mentally ill. So, people with your agenda directly interfere with our agenda.

This isn't the view of the vast majority of psychiatrists, and given the slant on this board is actually substantially to the right the psychiatric community at large, I'm guessing that only OPD and maybe a few other people will be sympathetic to this paradigm. Others will argue that the slot and what you choose to do with it is your business, and I should go @#$^ myself if I think otherwise. That's fine. I've never claimed to be a libertarian.

I'm not saying people with our agenda are saints or any crap like that. If we wanted to, we could work 100 hours a week for free, but we don't do that. But people who see psychiatry as a "business opportunity" are always going to get on the nerves of those of us who see psychiatry as "an opportunity to do some good for the marginalized of society while getting paid enough to live very comfortably."

Looks like there might be some fresh folks who are business minded! Sweet! I have to say, that the only reason a "commie pinko midwestern democrats" can live comfortably with their current income is because of the conservative and libertarian defenders. They are the ones manning the walls defenses of economic reward. Every specialty should thank their conservative and libertarian colleagues for giving a damn to fight for their ability to earn an income. Without docs in private practice striving for cash only practices, administrators, insurance companies, and the govenment would more readily be able to adjust the "usual and customary" fees. They define the true financial worth of a psychiatrist. Otherwise, we wouldn't be valued or paid more than a midlevel. For instance, keep your eye on neurosurgeons. Watch how much and how fast their income will fall in the coming years. They essentially (except for some spinal practices) can't practice truely independent and the system/insurance companies/hospitals/government are chipping them down.

I also believe that psychiatrists are needed in every venue of the field. This keeps open more diversity in the field. Less burnout when you have more options. This also helps keep psychologists from seeing a huge void and erroneously thinking that they are the perfect ones to fill in the gap.

You could also argue from the perspective of societal value that the cash only outpatient psychiatrist is more beneficial. They are helping society to help the more productive citizens to return back to work much faster. A wealthy "worried well" is more valuable than a chronic mentally ill patient on disability regarding financial contributions to society as a whole.

Or you can argue against this like you have from a need perspective. Those with the most need should get the most treatment irregardless of their long term prognosis. Either way, both are benefiting society. Both are helping people. Both are treating mental illness.

These premeds are different minded, but they have potential. Plus, medschool will change them in some fashion or another, as will the changing landscape of healthcare. Don't chase them off just yet.

 

[Sneezing]

Oh, and thank heavens for some business minded people. There are some articles out there on the AMA and other news outlets that detail the swinging pendulum of new attendings choosing hospital based practices over solo practices.

This is essentially walking away from a large chunk of responsibility and power and handing it directly over to CEOs and administrators. We may as well say, "No, I like it rough, please." Independent minded and solo physicians are the best people to be in a position to advocate for patients against larger bureaucratic policies, if these numbers slip, medicine will be a much different landscape and we will only have more headaches and angrier patients.

 

[OldPsychDoc]

...
I also believe that psychiatrists are needed in every venue of the field. This keeps open more diversity in the field. Less burnout when you have more options. This also helps keep psychologists from seeing a huge void and erroneously thinking that they are the perfect ones to fill in the gap.
....

I just betcha that they're going to have psychologists prescribing haldol to me to keep me nice and docile when I get to that re-education camp...

 

[Sneezing]

You are criss crossing your futures. If you ended up in a montana republican re-education camp, it wouldn't be psychologist giving you haldol. It would likely be a GP.

If libertarians were the dominate party they wouldn't have a camp because that is against freedom. But if they did, it would probably be a pharmacist prescribing the haldol, because the would be the best bang for the buck for cheapness/efficiency for a mere prisoner.

If the Dems had a re-education camp, it would probably be an upgrade, because the taxes would be too high to afford any other kind of housing on your own, and at that point you would be so tired of the propaganda you would drink the water. The water, by the way, already has haldol in it. No one would prescribe haldol in their camp because it took to much effort and money to train anyone to know what they are doing.

 

[carlosc1dbz]

You are criss crossing your futures. If you ended up in a montana republican re-education camp, it wouldn't be psychologist giving you haldol. It would likely be a GP.

If libertarians were the dominate party they wouldn't have a camp because that is against freedom. But if they did, it would probably be a pharmacist prescribing the haldol, because the would be the best bang for the buck for cheapness/efficiency for a mere prisoner.

If the Dems had a re-education camp, it would probably be an upgrade, because the taxes would be too high to afford any other kind of housing on your own, and at that point you would be so tired of the propaganda you would drink the water. The water, by the way, already has haldol in it. No one would prescribe haldol in their camp because it took to much effort and money to train anyone to know what they are doing.

Very well said. The pre meds are the future.

 

[michaelrack]

Very well said. The pre meds are the future.

Hopefully the pre meds, and not the nursing students😱

 

[OldPsychDoc]

Hopefully the pre meds, and not the nursing students😱

Well, the more the doctors talk about "concierge practices" and focus on cash flow, the greater the demand for midlevels to fill the gap...
Doctor shortage? 28 states may expand nurses' role

 

[Sneezing]

They are the ones fueling the push for concierge. Nurses are succesfully lobbying based on these principles:
1) They spend more time with patients (because we are too busy busting are rear ends trying to see as many people as we can, and we are simply more effecient)
2) They are cheaper to insurance companies (until they all get 100% reimbursement like the midwives do, which they are lobbying for)
3) There is a shortage of physicians. So they advocate a lesser trained "provider" is the solution

They are not smart parasites. A good one doesn't kill its host, but takes only enough from it to live itself. (D)NPs are over reaching and with it they are fueling the collapse of the system, and with it the quality.

If insurance companies and CMS pay us equally, that is by default, saying training and experience are equal.

Are you equal to an (D)NP? Don't forget they do have autonomous practice in many states...

 

[loveoforganic]

"If insurance companies and CMS pay us equally, that is by default, saying training and experience are equal."

It would seem more accurate to me to say "services rendered are equal", whether that changes your point or not.

 

[235750]

I always shake my head when I hear of people going into medicine for the money. It's not that I think it's immoral, but rather because they suck at math.

'Selling out', as someone put it, doesn't really pay well in medicine. It takes too long and pays too little, compared to other careers. Going to medical school is a bad investment from a financial perspective. And psychiatry?? Now that's hilarious.

Because in my experience, if you don't intrinsically enjoy this stuff, you will not make it to the point in your career where the extrinsic rewards of prestige and relative riches kick in.

This is beautifully said. As a non-traditional student, I can say this is completely true. I made a decent salary for years, but as OPD says, you have to love what you do. And I didn't, so that's why I'm paying just under 800k in opportunity costs to be here. Tack on my living expenses/tuition, and...well, I don't see how anyone can think this is a profitable venture.

I cannot wait to get back to treating illnesses. To those people who aren't, I really feel for you because I think it's gonna be a rough ride.

 

[jettavr6]

I just betcha that they're going to have psychologists prescribing haldol to me to keep me nice and docile when I get to that re-education camp...

That certainly might happen if you scare off future applicants to our field... Less psychiatrists means more ammo for the psychologists in their quest for prescribing privileges.

 

[abcxyz0123]

I always shake my head when I hear of people going into medicine for the money. It's not that I think it's immoral, but rather because they suck at math.

'Selling out', as someone put it, doesn't really pay well in medicine. It takes too long and pays too little, compared to other careers. Going to medical school is a bad investment from a financial perspective. And psychiatry?? Now that's hilarious.

I cannot wait to get back to treating illnesses. To those people who aren't, I really feel for you because I think it's gonna be a rough ride.

uhh ok. you do your thing, we'll do ours, no need for the condescension. i'm in it for the potential of good money and free time as much as i am in it for how insanely interesting the field is. as a 3rd year, i'm having a blast, my friends in psych residency are having a blast, and my mentors in private practice child psych are making insane money and are having a blast as well.

 

[jettavr6]

uhh ok. you do your thing, we'll do ours, no need for the condescension. i'm in it for the potential of good money and free time as much as i am in it for how insanely interesting the field is. as a 3rd year, i'm having a blast, my friends in psych residency are having a blast, and my mentors in private practice child psych are making insane money and are having a blast as well.

I think the vast majority of practicing psychiatrists would encourage you to pursue your career path within the field of psychiatry. There are many different practice models, styles, and approaches. Good luck to you!👍

 

[sunlioness]

I don't think there's anything inherently wrong with wanting to make a lot of money. And I don't think anyone here has said that there's anything inherently wrong wtih wanting to make a lot of money. And if you love psychiatry and working with this population and you also like that you can make good money at it, then I think that's awesome. Because the love for what you do is still there. That's what's important.

Going into psychiatry or any field of medicine, not liking what you do, but in the expectation of becoming fabulously wealthy at it is just not smart. The investment in money and time to get to the place where you can even pay your bills is immense. And then once you get there, you have to work really hard to be one of the ones who pull down the big salaries. If you don't actually like being a doctor, there are far easier ways to become wealthy. If you do like being a doctor and think it's awesome that you can become wealthy doing what you love, well, then I would tend to agree with you. 🙂

 

[peppy]

Even though I don't really identify as a bleeding heart liberal, I wouldn't really recommend planning on a career in concierge medicine in psych.
The middle class people who have simple, mild depression/anxiety are the low-hanging fruit that FPs and PAs/NPs will be gunning for too. FPs may be better able to attract these patients since it is more socially acceptable to many people to see an FP than a psychiatrist...and NPs may even be perceived as more approachable than doctors since they have started to build this rep of "having more time for patients" and all that.
The super-wealthy people who can afford to have a personal doctor at their disposal? Well, I really don't think that there are that many rich executives clamoring for intense psych care since they can use their money and power to avoid having to get proper treatment (Case studies: Michael Jackson and Howard Hughes).
If you want to be a psychiatrist, you really do need to be comfortable dealing with the homeless chronic schizophrenic who hasn't bathed in six months. In residency you will certainly see plenty of them even if you do build a practice later of wealthier, less ill patients.

 

[whopper]

I am providing a service, and know it will be my own choice.

So are hookers, hit-men, etc.
Did you write the above into your personal statement when you applied for medical school?

Whether or not you acknowledge it, being a doctor carries with it several ethics, including specific legal standards that we obey a fiduciary responsibility to our patients. By legal, professional, and ethical standards we are providing more than a simple service.

If you are going to medschool for the money, you are going into the wrong profession. If you got the brains and discipline to work the ungodly hours, if you're after the money, I suggest you get an M.B.A. and/or work in a hedgefund.

If you really want to pursue the type of practice you are suggesting, your most likely chance of succeeding is by actually having some medical weight to your name. Why would anyone want to go to a psychiatrist and pay a lot of money out of pocket when that person is likely wealthy enough to have medical insurance? Only if that psychiatrist is extremely good, or if you are willing to practice in an extremely underserved area.

To be that good--you're going to have to spend a lot of time doing things that are not connected with money...e.g. lots of research, a great clinical reputation, etc. These take years to accomplish, and you will likely be working with the "marginalized" as you put it.

 

[rama kandra]

I would actually beg to differ on hookers. Lots of those women have literally no choice since they would not have the lifestyle or education to promote alternative careers. Many hookers are doing it for money and to survive - they don't know what else they would do. I am suggesting that after I am educated and have my training, I will do whatever I please with it. I am not bound to any person who defines what I ought to do with it. I don't advocate breaking the law or that I will not treat my patients.

As for what I wrote in my PS - based on the number of rejections I got they must have not liked mine (which had a nice story about my desire to be a physician, believe it or not). But thats neither here nor there, since I got accepted to one.

If you are working in a career where you are doing things that are not your own choice, you have a different definition of autonomy and freedom than I do.

 

[whopper]

Lots of those women have literally no choice since they would not have the lifestyle or education to promote alternative careers. Many hookers are doing it for money and to survive - they don't know what else they would do.

True, but then again some aren't. Many of the prostitutes I had as my patients chose to have their lifestyle because they would rather earn a several hundred a dollars a day only doing a 3 hours of work.

OK, so for fairness sake, let's say my comparison that is not valid for the type of hooker that was forced into the business, but let's also say it is valid for the type of hooker that was not forced into the business.

Hey, most hit-men and mobsters I've seen weren't forced into the business.

(which had a nice story about my desire to be a physician, believe it or not).

Was that story actually honest?

I don't know if you caught this but I'm actually trying to do you a favor. You might be investing a lot of time and effort into something that might not be what you want.

 

[rama kandra]

My story was very brutally honest. Why on earth would I, a college educated person chose to be a doctor of all things, a psychiatrist? I obviously love the career and ideas behind the science and like neurochemistry. I want to help influence this field - believe me I would be far wealthier being in a career like finance where some of my family members are. I know where I belong but I also have a strategic vision. I prefer not to be marginalized and do work that I find less rewarding after spending 10 years preparing and paying for it. A phd does not have the burdens I will have, they are free to work for less pay and work for an institution including the government. Not me, not likely. Private practice seems more appealing, so really who can blame me? It isn't my fault medical school costs 200k or that I will work for limited pay for many years. If those facts changed I would change too.

This stuff about hookers and gangsters is extreme and I won't go into it, since I don't place any value in what they do, it is not a life I imagine I want but that is not my place to make moral accusations and tell other folks what to do.

--ps I would also say anybody besides a DO/MD/physician involved in the mental health complex has far less burden. Psychologists are not bleeding the way most in debt residents are, nor are any social workers under the same level of training. I don't care what they say about their careers, they are walking through a bed of roses.

 

[whopper]

Fair enough. I'm glad you quickly posted because the words I wrote could be interpreted as hostile, or just devil's advocate. On my part it was mostly judge devil's advocate.

IMHO, people actually do deserve to make plenty of money if they've done great work to advance the field. There's a particular psychiatrist in my area with a national reputation, he bills a heck of a lot of money for private consultation on very very tough cases. I'm talking cases that most would never see in an entire career, and he comes up with brilliant suggestions that make me shudder with awe in his knowledge. I have no problem with him giving a large bill.

When I said I was actually trying to do you a favor, I meant that I wanted you to be aware that medicine is not the best road if your primary motivation is money. You seem to be aware of that.

Based on what you told me, I actually wish for you to be successful, though ethically, I recommend that if you do the type of work you suggest, you have the talent to merit the pay.

 

[rama kandra]

Of course many years of hard work and reputation are necessary for such a thing. I am not advocating running out without those things, but just slightly. I don't want to get stuck in the mismanagement of healthcare professionals. Secondly I took no offense to what you said, you are a rational person and so am I. Nothing good is accomplished without some rational framework and I encourage anybody to question the premises we all make from time to time (my sig!!)

And further I have a favorite quip from Buffett who wrote about his favorite investment banker, Byron Trott who started in a humble midwestern way but understands the business world so well that he is Buffetts second hand man for dealmaking. One thing Buffett does not like is overpaying, or high bonus types but he wrote on Trott once, saying 'it pains me to say this but he deserves his fee.'

That is what I aspire to. Nothing less.

 

[carlosc1dbz]

uhh ok. you do your thing, we'll do ours, no need for the condescension. i'm in it for the potential of good money and free time as much as i am in it for how insanely interesting the field is. as a 3rd year, i'm having a blast, my friends in psych residency are having a blast, and my mentors in private practice child psych are making insane money and are having a blast as well.

Well said, there are so many different types of people in medicine, it would be silly to try to make everyone out to be the same. Its like saying if you dont practice in academics your just money hungry! That would be ******ed obviously, because some people want autonomy which private practice gives them. Even amongst the people that want to go into private practice, there is a broad range of goals and personalities. Some people want to work less, some want to work more, some want more money, some dont want a lot of money. There is no need to criticize others for having their own goals and objectives.

 

[masterofmonkeys]

As a hardcore libertarian, I am highly amused by this thread. I deffo agree with the people who have said that medicine is not the field to go into if you want to make a lot of money.

This was briefly tenable in the 80s and 90s for certain specialties (ROAD, uro, neurosurg) due to the combination of the RVRBVRFHS nonsense, low med school tuitions, and the absurd differential between proceduralists versus non.

But almost all of my college friends will out earn me (or would have, had they worked similar hours) over their lifetimes. Same is true for anyone who has graduated during the era of cutbacks, malpractice insurance, increased government care, and skyrocketing tuitions, not to mention the increasingly progressive tax climate I am expecting to continue for some time.

Meh.

And while the thought of working with the 'worried well' nauseates me in the extreme, is there something wrong with not working with the severely mentally ill? Can psychiatry offer substantial health and quality of life benefits to people who don't have treatment resistant depression, bipolar, or a psychotic disorder?

I certainly believe so. Hell, I won't lie, that's why I went into psychiatry. Because I saw the vast potential for maximization of mental health to pay dividends throughout the rest of one's life. Don't get me wrong, I enjoy working with the severely mentally ill, and I enjoy learning how to do so. But that is not going to be something I spend the rest of my life doing.

My patient-base will be people with chronic pain and disabilities. Many of them may not even have severe enough psychiatric issues to be formally diagnosed with a major mood or anxiety disorder. But I hope that I'll be able to help them live fuller lives. Is that wrong?

I think it's a bit presumptuous of us to define the kind of patients who deserve our attention. Or to state that patients whose disease is not severe enough not worthy of our care.

But, like I said in the beginning, I'd rather shoot myself in the face than charge 500 an hour to see the worried well.

 

[whopper]

I have no problems with people making a lot of money in this field if it's done honestly. That does not include someone having some type of private practice where they do poor work and mislead patients.

As I mentioned above, a nationally recognized psychiatrist does very expensive consultation cases on difficult cases. IMHO he earned that money. He truly brought a level of expertise not regularly available from most psychiatrists I've seen. IMHO if he just earned a typical salary on the order of what an average psychiatrist made, he would not be able to provide the services he does, that do benefit others. He would've been bogged down with typical cases, and he would not have had the time or interest to pursue the very difficult "House" type cases that stumped over a dozen psychiatrists in one hospital.

But to support that level of pay, IMHO the psychiatrist needs to be of a special level of talent.

Market-forces unfortunately IMHO do not work well in medicine. This is not a type of field where if a doctor does a bad job, the patient can tell and just go to another doctor. There is no supply-demand curve that works well for us. We have to balance the money factor with some ethics, though where one begins and the other ends, there's going to be a lot of disagreement.

As for being marginalized at work, I too agree that good psychiatrists deserve better than that, and if they want to use some private aspects of medicine--all the better. While I wasn an attending last year, I was told I would be promoted to the highest pay grade the state would offer because of my performance, a whopping 2-3% higher than my current pay. The state facility also kept dropping the hardest cases in the hospital on my lap, while I saw other psychiatrists who IMHO weren't doing a good job continue their mediocre work. In short, I felt like I was being punished for trying to do good work while they were being rewarded for mediocrity. Several of these doctors were making much more money that I was from the state because they had several added years on their seniority, but the quality of their work was IMHO low.

 

[Sneezing]

The state facility also kept dropping the hardest cases in the hospital on my lap, while I saw other psychiatrists who IMHO weren't doing a good job continue their mediocre work. In short, I felt like I was being punished for trying to do good work while they were being rewarded for mediocrity. Several of these doctors were making much more money that I was from the state because they had several added years on their seniority, but the quality of their work was IMHO low.

I too have seen this. This is what happens with government jobs. This is what we can all expect in medicine with the expansion of Obamacare. 🙁

This is partly why I personally wish to pursue private practice. I have no desire to be a slave of the insurance companies nor a slave to the government or the colleagues at a government job.

 

[whopper]

I too have seen this. This is what happens with government jobs. This is what we can all expect in medicine with the expansion of Obamacare.

This is partly why I personally wish to pursue private practice.

My sentiments as well. That is why I will not work 40 hrs for the state after fellowship. I gave it my all, and all the while, the doctors doing mediocre work, the establishment just took their problem patients and gave them to me, while the mediocre doctors got to keep easy patients who in reality IMHO should've been discharged. It got to the point where I pretty much had an inordinate amount of some of the most violent patients in the state on my unit. I didn't feel that was fair to me, my staff or the other patients on my unit.

I at any point will always want some difficult cases. I truly enjoy a challenge, and trying to put the feather in the cap, especially when it will lead to someone becoming mentally healthier. I did not enjoy being overburdened, exploited, and feeling that my unit was not a safe work environment.

The state does reward better workers but only at rate of pay just 2-3% higher. If you're working in the private sector, that could be, well 10%, maybe even 200% higher. I don't really want to exploit my work-ethic for the state in an effort to get an administrative job because then guess what? I'll be trapped in a system bogged with unions and doctors where I feel they deserve better pay but I can only offer than an extra 3%.

There was an oft-repeated saying that after a few years, all the good doctors would leave the institution, and only the bad doctors stayed. Of course I've seen exceptions, but I did feel there was truth in that trend for many.

The state pay is on the lower side, so state institutions do not have lines of doctors willing to join them. As a result, they are willing to hold onto mediocre doctors.

I refuse to do sub-standard work. I feel that would be a violation of my Hippocratoc Oath. Working hard, even though I felt I was marginalized did have several benefits. I have earned a very good reputation and it did lead to me being offered work at some very lucrative private practices. One of the doctors I work with at the state facility has made several attempts to have me work with him in a lucrative practice because he thought I did good work. Word of advice--no matter what job you have, don't ever do poor work. You're a doctor, your patients deserve better, and it will pay off in the long-run. If you don't like your job, just finish off your contract and get out of that job, but continue to do good work.

I will continue to work for the state after fellowship only because I was told what happened above will not happen again, I love forensic work, and most forensic work is only available through the state, and I have the oppurtunity to work with someone who IMHO is one of the best people in the field who works with the state for research purposes. I strongly considered not working for the state because had I just worked private practice 100%, I would making much more money. I stated this before but the private practice pay is about 2x as much. I'm planning on doing 30 hrs state/15-20 hrs private after fellowship. If I feel that I am exploited again, I will probably leave the state and focus on private practice and possibly working in an academic setting.

But on the flip-side....

I have seen some private doctors that I feel do terrible work, and some of their patients continue because they don't know any better, and believe the higher cost will mean higher quality.

Doctors are like wine in America. A restauranteur of a 5 star establishment told me he found an incredible wine that he could provide his customers at only $25 a bottle. No one bought it because Americans don't know their wines. When he upped the price to $150 a bottle, people were buying it hand over fist and complementing it. He said had his restaurant been in France, they would've known it was a great wine at an affordable price, and would've known he was bilking his customers. In America? They can't tell what they're drinking.

 

[Sneezing]

Re: Wine

The literal response to this is American's don't really drink that much wine. We are a beer and liquor drinking nation. The other part is that europe has more stringent wine laws that prohibit alterations to the pre-fermented juice. You can't add more sugar to make it sweeter or ramp up the alcohol. You are stuck with what you got. Here in the US you can tamper with your wines. In other words we are more likely to have just good wine. Without the bad wines to put it in context your a little desensitized to quality.

Now medically, we would know how to sniff out the good doctors if people were actually paying for their care. If people were paying with their own money from their own wallet they would doctor shop a lot more. They would communicate with their friends a lot more. Internet doctor rating sites would actually mean something. But America doesn't, so quality doesn't really matter, hence Obamacare expansion.

I hope you don't get burned at your upcoming state job. Well wishes for you.

 

[robmcc1]

Re: Wine

Now medically, we would know how to sniff out the good doctors if people were actually paying for their care. If people were paying with their own money from their own wallet they would doctor shop a lot more. They would communicate with their friends a lot more. Internet doctor rating sites would actually mean something. But America doesn't, so quality doesn't really matter, hence Obamacare expansion.

I hope you don't get burned at your upcoming state job. Well wishes for you.

I actually think the wine metaphor is pretty apt; because patients don't know as much about medicine as doctors they often can't tell who's a good doctor or sometimes they don't even want a good doctor. What I mean is - a doctor can become very popular and earn a lot of money if he tells people what they want to hear, orders whatever test they ask for, and prescribes whatever they want to be prescribed: e.g. Michael Jackson's doctor. This is why the free market isn't the final answer for medicine - the free market will benefit the best salesmen but not necessarily the best doctors.

 

[whopper]

Now medically, we would know how to sniff out the good doctors if people were actually paying for their care. If people were paying with their own money from their own wallet they would doctor shop a lot more.

I don't think this is the case for most. If a doctor tells a patient something is going on, and the patient does not trust the doctor, gets a 2nd-different opinion, the patient does not know who to trust.

It's hard to gauge which is the good doctor when the patient can't tell which doctor is more correct.

Kinda like going to 3 car mechanic and getting 3 very different opinions. You don't know who's right.

This is why the free market isn't the final answer for medicine - the free market will benefit the best salesmen but not necessarily the best doctors.

Agree, though I also do believe there are some benefits to having some aspects of capitalism in our medical system. IMHO, the pure capitalism model doesn't work well with most aspects of medicine because it's not like a hamburger. It's not like you can sample 5 doctors's service where the customer knows exactly what he should expect.

I do think some aspects of capitalism do work in medicine...e.g. being able to compare various company's insurance rates, but this is just one aspect of a multifaceted issue that even doctors don't fully understand. If you asked most doctors about things like PPOs, HMOs, capitance-based pay, lots of them wouldn't even know.

 

[rama kandra]

This is what makes me question how 'capitalist' our system is currently. It isn't. Primary care physicians are exactly what good medicine and economics represent. They have the traits of having long term patient relationships, early detection, control obesity and longer outcome issues. Why primary care is not considered sexy, or gets such low pay makes me believe it is not running on the capitalist model.

Primary care should be according to my ideal, the perfect type of medicine that rewards long term frequent patient interaction because it is economic (helps lower obesity better than specialists) and patients generally find out over time if their doctor is treating them well. PCP doctors.... these should be higher paid folks but the interference of regulation (insurance, policy) makes it unattainable. I hope this changes over time.

 

[carlosc1dbz]

This is what makes me question how 'capitalist' our system is currently. It isn't. Primary care physicians are exactly what good medicine and economics represent. They have the traits of having long term patient relationships, early detection, control obesity and longer outcome issues. Why primary care is not considered sexy, or gets such low pay makes me believe it is not running on the capitalist model.

Primary care should be according to my ideal, the perfect type of medicine that rewards long term frequent patient interaction because it is economic (helps lower obesity better than specialists) and patients generally find out over time if their doctor is treating them well. PCP doctors.... these should be higher paid folks but the interference of regulation (insurance, policy) makes it unattainable. I hope this changes over time.

Many times I too have found myself wondering about the economics of medicine. The US population is growing exponentially and the supply of doctors has not grown at the same rate, thus the shortage has been increasing over the last 30 years. The thing is, that the salary for doctors has been decreasing steadily over the same period of time that the population is growing. It makes no economic sense to me. I know that doctors do not practice in a free and open market, or else they would earn much more as time progressed, as the shortage would get worse.

I am not in favor of unions but I am not sure how exactly doctors can protect themselves from the government and their abusive reimbursement practices.