Geri/Psychosomatic fellowship

[DD214_DOC]

I am continuing to develop a great interest in geri psych as well as psycosomatic psych. I have found that I really enjoy my time on the consult service and dealing with issues of dementia and the related neuropsych of such disorder much more than I enjoy inpatient psychiatry; I have yet to do any outpatient, so I have no idea how I will like that.

Having said that, I am *seriously* considering applying to the available combined geriatric/psychosomatic fellowship available to me in the military. I have been told that it basically goes unfilled all the time.

My question is, is it feasible to have a geri psych/CL based practice and do well? I'm not out to make tons and tons of money, but would income be comparable to other areas of psychiatry? How would you even go about doing this? Mixed outpatient and consult work at a nearby hospital? Outpatient with nursing home work?

I'm working with a neurologist right now who has basically started a, "neuroscience center" where he has multiple disciplines handling stuff like dementia. I could potentially see myself doing something similar.

Any thoughts? Or should most people who like putting food on the table stay away from geri and c/l?

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[BobA]

I am continuing to develop a great interest in geri psych as well as psycosomatic psych. I have found that I really enjoy my time on the consult service and dealing with issues of dementia and the related neuropsych of such disorder much more than I enjoy inpatient psychiatry; I have yet to do any outpatient, so I have no idea how I will like that.

Having said that, I am *seriously* considering applying to the available combined geriatric/psychosomatic fellowship available to me in the military. I have been told that it basically goes unfilled all the time.

My question is, is it feasible to have a geri psych/CL based practice and do well? I'm not out to make tons and tons of money, but would income be comparable to other areas of psychiatry? How would you even go about doing this? Mixed outpatient and consult work at a nearby hospital? Outpatient with nursing home work?

I'm working with a neurologist right now who has basically started a, "neuroscience center" where he has multiple disciplines handling stuff like dementia. I could potentially see myself doing something similar.

Any thoughts? Or should most people who like putting food on the table stay away from geri and c/l?

No expert here, but I'm guessing that you'd be limiting your income pretty severely because you'd only be seeing medicare pts in Geri clinic and mostly medicare/medicaid pts on CL. So your salary would be dependent on what medicare wants to pay you. Also, from my outpatient geri clinic experience (only a few months so far) the geri outpatient visits take 2-3 times longer than a younger person's visit because (1) the person moves/talks slowly, (2) can't give great info so you have to interview the pt and their caregiver and (3) you have to spend time performing more detailed cognitive tests like MOCA or Trail making tests that you're not getting paid for. So it would seem as though you could see fewer pts in a day in a Geri clinic which would also limit your earning power. You would, however, get a place in heaven.

 

[billypilgrim37]

The value of the consultant and the geriatric psychiatrist isn't so much in direct reimbursement but in the value you offer to institutions. Those aren't great fields for private practice, but they are great jobs for a system to pay for. For all the good work consul psychiatrists do, they also free up beds and speed dispositions, resulting in increased profits for hospitals. I'm guessing DS makes more money for his hospital system through assisting with disposition than he does with being an awesome consult psychiatrist billing for his work. Or at least, a lot of his value (funding stream and pt care benefits) to the system goes well beyond the remuneration they bill for.

I think there would be parallels in geriatrics as well. Some nursing home psychiatrists eat what they kill (okay, that's a pretty bad turn of phrase in this context), but many are hired to do more than that, because a good geriatric psychiatrist available to work with staff or actually have family meetings can save a nursing home money and improve care.

Doing the fellowships frees you up to do what you want. If you find in the end that being a general adult psychiatrist is going to pay you more money, you can still do that. But if there is something else lucrative that can be created now or later in these fields, you're going to have the credentials and the expertise to take advantage of it. It's a tad bit of a gamble, but a fairly safe one. The worst thing that happens is you lose about 100k of income over your lifetime. The best things that could happen could be substantially better than just gaining 100k of lifetime income.

This coming from a guy who is planning on more than one clinical fellowship. Maybe I'm just trying to talk myself into thinking the things I want to do actually make sense.

 

[michaelrack]

Docs practicing geri psych (not necessarily fellowship trained) can make big $ doing inpt psych- you spend 20 minutes doing an admission of an agitated nursing home patient, and then 5 minutes at least every other day after that while they are hospitalized. The geri psych doc adds a small dose of atypical antipsychotic and has a pcp type or NP do a medical w/u.

Of course, if you do a good job and spend more time with patients, you will make less $. I recommend doing a good job

 

[cleareyedguy]

If you do general C-L, about half of your patients would be over 60.

As said above, neither geri nor c-l are especially lucrative on their own. By being value added to the hospital, however, you can get significant hospital funding so that your overall income is at least that of anyone else in the psych dept outside of the chairman's office.

 

[DD214_DOC]

Ok, so this leads naturally to my next question. My other fellowship interest is in forensic psych. I imagine that this wouldn't really add much to your institutional appeal, but I surmise it could potentially add a considerably amount to your private practice earning potential?

I do think, however, that as we learn more about the neurology of dementia and other psych stuff in combination with the increasingly-older population, geri psych will become more valuable.

I haven't really decided which route to take. I realize I have a couple years, but I'm trying to tailor my research during residency to my fellowship interests to help my application. (And because I'm actually interested)

 

[billypilgrim37]

Capacity issues hit all 3 very well. Hit that hard!

Actually have a friend that just finished up a very prestigious forensic fellowship and just started a very prestigious psychosomatic fellowship. Don't think he had any interest in geri per se.

 

[michaelrack]

I do think, however, that as we learn more about the neurology of dementia and other psych stuff in combination with the increasingly-older population, geri psych will become more valuable.

)

If by "valuable" you mean needed, then yes. If you mean better reimbursed, NO. Medicare cuts are coming

 

[digitlnoize]

If by "valuable" you mean needed, then yes. If you mean better reimbursed, NO. Medicare cuts are coming

And as the cuts come, more and more docs will stop accepting Medicare. Rates will either be forced to rise, or people will be forced to buy their own private insurance, if they can afford it.

Welcome to our two-tiered system folks! The young poor get medicaid, which no one takes. The old poor get Medicare, which no one will take. Everyone with money struggles to pay for private insurance, which is accepted by most doctors, but still costs an arm and a leg (literally) and that lack of mobility after paying the bill really get you down. Then they come to see the psychiatrist for their depression, but we only take cash, preferably Chinese.

 

[michaelrack]

The old poor get Medicare, which no one will take. Everyone with money struggles to pay for private insurance, which is accepted by most doctors, but still costs an arm and a leg (literally) and that lack of mobility after paying the bill really get you down. Then they come to see the psychiatrist for their depression, but we only take cash, preferably Chinese.

Agree in general. Although those with $/insurance are less likely to need the services of a geri psychiatrist- a geri fellowship probably isn't a good investment in monetary terms