In non-medical fields, those who earn high income frequently test the market regarding their worth. And when they find greener pastures, they switch jobs -- either promoted internally or externally. Is this something doable in psychiatry? Any real life example of it being done?
High Achievers and Job Hopping Every 2 Years
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Of course. Why wouldn't it be doable? It's a portable field and assuming you didn't sign a contract for more than 2 years, you can leave in 2 years if you like. But my question is why would you want to? In other professions, people are usually younger when they start working. That's not the case in medicine. After you've dedicated your young adult life to this profession, you're likely preparing to enter middle age by the time you're done with training. Do you really still want to move around every 2 years just to "test your worth"?
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It isn’t the same in the medical world. Reimbursement from insurance doesn’t change with MD experience.
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I mean I could name plenty of examples at our shop of physicians who have jumped up the admin ladder with commensurate increases in salary. Also rockstar researchers getting poached from less fancy places. Does that address your question or not what you had in mind?
I imagine many psychiatrists don't do it as often because they build long-term relationships with patients. Also medical education is an exercise in beating the risk tolerance out of people.
I imagine many psychiatrists don't do it as often because they build long-term relationships with patients. Also medical education is an exercise in beating the risk tolerance out of people.
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Sweeping generalization here, you will not find upward mobility in medicine, overall. After you complete residency and even ventured into the getting the sticker on the wall that says board certification, you achieved the max, and you will get paid as much as the doc near retirement. As it is should be. Our system beats you for 4 years to train you to be the experts who runs circles around mid-levels, and pharmacists, etc. The financial ceiling is fixed by the payment structure with insurance companies. You do one new evaluation coded with CPT 90792, and insurance company XYZ may pay you and every Psychiatrist for miles around $JKL (and even the ARNPs...).
Now finding the cracks in my sweeping generalization above, yes, some large health systems have some upward mobility with increasing administration levels and declining clinical care levels. But these positions are not always a guarantee of higher pay, some places perhaps, others no so much. The devil is in the details of the admin contract. Is it by hour? Is it by lump sum stipend? Do they require in depth documentation of hours on a time sheet? Is it by simply adding artificial wRVUs to your existing wRVU production compensation?
Some medical director roles for inpatient units may offer stipends in ways that the work effort to get the stipend is less intense then if you were to be doing 100% clinical, so in that regard its a financially positive upward movement. Med Dir roles typically list wanting 5 years experience post residency from what I've seen.
As Clausewitz2 notes, some researchers get poached from other institutions. But I wouldn't count on there being some thing other than a change in geography or institutional pride in which get that's better (Hurumph Hurumph, I work for Invasive Weed Ground Cover Institution Beta Omega). I could be wrong, and that they get more funding, or perhaps a stake in patents, but psych isn't exactly a patent robust field for psychiatry researchers and funding doesn't necessarily mean more of that money goes to salary of the researcher. Academic types might use their clout to write books, or do expert witness testimony, or open side private cash pay practices, etc but that's more their own hard work and ingenuity then it is rising up a ladder. The academic docs who put themselves out there as pharma CSW, are essentially over, most of those folks have popped up in the news in previous 10-20 years and been pushed out of academia (others on here, correct me if I'm wrong on this one).
Similar vein of rising up ones own ladder, docs who open their private practice can potentially blow away the median/average stats of income by applying the sweat equity of building their own practice/business. Some use the knowledge and skills acquired from other 'entry' level jobs at the Big Box Shops. I am burgeoning example of this self promotion into private practice, not yet 'made it' but working at it. Others on here already have 'made it' in their self promotion to becoming one of the 'free folk' to quote GOT. Some docs have taken the private practice to a more extensive extreme and opened up multi office chains (look to CA and AZ for these examples).
Here is a profile of one EM doc who segued from medical group & academia positions into the corporate side of medicine.
springstone.com
Here is a profile of one Psych who climbed academia, while having a side consulting business that segued into corporate medicine.
springstone.com
Now finding the cracks in my sweeping generalization above, yes, some large health systems have some upward mobility with increasing administration levels and declining clinical care levels. But these positions are not always a guarantee of higher pay, some places perhaps, others no so much. The devil is in the details of the admin contract. Is it by hour? Is it by lump sum stipend? Do they require in depth documentation of hours on a time sheet? Is it by simply adding artificial wRVUs to your existing wRVU production compensation?
Some medical director roles for inpatient units may offer stipends in ways that the work effort to get the stipend is less intense then if you were to be doing 100% clinical, so in that regard its a financially positive upward movement. Med Dir roles typically list wanting 5 years experience post residency from what I've seen.
As Clausewitz2 notes, some researchers get poached from other institutions. But I wouldn't count on there being some thing other than a change in geography or institutional pride in which get that's better (Hurumph Hurumph, I work for Invasive Weed Ground Cover Institution Beta Omega). I could be wrong, and that they get more funding, or perhaps a stake in patents, but psych isn't exactly a patent robust field for psychiatry researchers and funding doesn't necessarily mean more of that money goes to salary of the researcher. Academic types might use their clout to write books, or do expert witness testimony, or open side private cash pay practices, etc but that's more their own hard work and ingenuity then it is rising up a ladder. The academic docs who put themselves out there as pharma CSW, are essentially over, most of those folks have popped up in the news in previous 10-20 years and been pushed out of academia (others on here, correct me if I'm wrong on this one).
Similar vein of rising up ones own ladder, docs who open their private practice can potentially blow away the median/average stats of income by applying the sweat equity of building their own practice/business. Some use the knowledge and skills acquired from other 'entry' level jobs at the Big Box Shops. I am burgeoning example of this self promotion into private practice, not yet 'made it' but working at it. Others on here already have 'made it' in their self promotion to becoming one of the 'free folk' to quote GOT. Some docs have taken the private practice to a more extensive extreme and opened up multi office chains (look to CA and AZ for these examples).
Here is a profile of one EM doc who segued from medical group & academia positions into the corporate side of medicine.
Robert Maha, M.D. - President & CEO | Springstone Leadership
Robert Maha, M.D. is the President and Chief Executive Officer at Springstone, Inc. View professional background & clincial experience information here.
springstone.com
Here is a profile of one Psych who climbed academia, while having a side consulting business that segued into corporate medicine.
Jeremy Musher, M.D., Chief Medical Officer | Springstone
Jeremy Musher, M.D. is the Chief Medical Officer, Chief Clinical Officer at Springstone. View professional background and clincial experience information.
springstone.com
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I suppose you could job hop every 2-3 years to try and capture sign on bonuses from the Big Box Shops. However, it also means you are likely to be building up your patient panel every few years, and that gets exhausting doing that many outpatient new evals so frequently. Could be worth it if living a slower locums type lifestyle is appealing?
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Working your way up the (usually academic) administration ladder will eventually have a payout, especially if you make it to the C-suite. That is a significant minority of docs, a competitive pool, and a different skill set than rank-and-file patient care.
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I've done several jobs, work for a state hospital, private practice, ACT team, etc. Some of the variations are because they were different clinical scenarios within the same job. E.g. in a big university hospital you can do several things but it's still the same employer, but I've had 7 employers during my career outside of residency.
At least for me I felt I had to test the boundaries. Why? Cause I didn't know if the grass was greener on the other side. There are no go-to guides for this type of thing other than this forum and no one here had the expertise to guide me at the time I needed it. When I first came to the forum most of the people here were other residents. There was one particular attending, doesn't come on here anymore, who had a self-professed psychotherapy style of calling out patients for being wrong based on circumstantial evidence, and prided himself on it, who whenever someone here had issues he'd bark that residents shouldn't complain. Yeah right like I was going to use that guy as a guide.......not.
State institutions: Stable work, stable hours, good retirement, good benefits, BUT.....below standard pay, most of your colleagues aren't sharp, several employees don't do their work to an acceptable standard, depending on the facility your work environment could be a dungeon. While I worked in one in Ohio, thankfully, that hospital was one of the best in the country in terms of design, etc. The worst thing about the job is several people in state hospitals hate their job but because they want to get the next tier of benefits stick with it. There's enough people like this to drag the general positive feeling you may have down.
Universities: Stable work, good benefits, very sharp colleagues, extremely large learning potential, able to do things such as research and teach if you enjoy, BUT...potentially below standard pay, possibly incredibly bad hours with you being called a lot in the middle of the night. Depending on the institution the environment could be bad. E.g. the last university I worked for it took security 30 minutes to show up when patients became violent and when I brought it up with the higher-ups I was met with ambivalence....until I brought it up to the head of the department who was in utter shock. Problem for me was the head of the department (as great a guy as he was) didn't work in the trenches and was focused on research, and the upper guys who were in charge of things like the unit were ambivalent to incredibly bad standards.
I recommend all new graduates to do some university work for a few years cause there's still so much to learn after residency.
Private Hospital: Tend to have very nice work environments (e.g. lobby looks like a hotel lobby, rooms are nice, nice doctor's lounges). Good benefits, standard pay.
Private Practice: It's all up to you. You can have a crappy office but if so you bought it. If you're smart, talented, and can stomach the learning curves of starting a new business you're fine. If there's something you don't like about the practice you can fix it cause you're the owner, but emphasis on YOU GOT TO FIX IT. You will have to fire employees, check up on numbers, etc. It's your business.
For me that's fine. Cause if there's a problem I'm the type of guy who'll fix it on the spot, and try to see if there's a better way to handle it, and if so implement it.
ACT teams: If you got a great team you're fine. If not you're screwed. Otherwise like working in a state institution.
Factor in that the above are general guidelines. While most state hospitals aren't exactly up to date environments, a few are. Many universities are on top of getting things fixed quickly, others aren't
Also you could use one of the above to spring off to something bigger and better.
At least for me I felt I had to test the boundaries. Why? Cause I didn't know if the grass was greener on the other side. There are no go-to guides for this type of thing other than this forum and no one here had the expertise to guide me at the time I needed it. When I first came to the forum most of the people here were other residents. There was one particular attending, doesn't come on here anymore, who had a self-professed psychotherapy style of calling out patients for being wrong based on circumstantial evidence, and prided himself on it, who whenever someone here had issues he'd bark that residents shouldn't complain. Yeah right like I was going to use that guy as a guide.......not.
State institutions: Stable work, stable hours, good retirement, good benefits, BUT.....below standard pay, most of your colleagues aren't sharp, several employees don't do their work to an acceptable standard, depending on the facility your work environment could be a dungeon. While I worked in one in Ohio, thankfully, that hospital was one of the best in the country in terms of design, etc. The worst thing about the job is several people in state hospitals hate their job but because they want to get the next tier of benefits stick with it. There's enough people like this to drag the general positive feeling you may have down.
Universities: Stable work, good benefits, very sharp colleagues, extremely large learning potential, able to do things such as research and teach if you enjoy, BUT...potentially below standard pay, possibly incredibly bad hours with you being called a lot in the middle of the night. Depending on the institution the environment could be bad. E.g. the last university I worked for it took security 30 minutes to show up when patients became violent and when I brought it up with the higher-ups I was met with ambivalence....until I brought it up to the head of the department who was in utter shock. Problem for me was the head of the department (as great a guy as he was) didn't work in the trenches and was focused on research, and the upper guys who were in charge of things like the unit were ambivalent to incredibly bad standards.
I recommend all new graduates to do some university work for a few years cause there's still so much to learn after residency.
Private Hospital: Tend to have very nice work environments (e.g. lobby looks like a hotel lobby, rooms are nice, nice doctor's lounges). Good benefits, standard pay.
Private Practice: It's all up to you. You can have a crappy office but if so you bought it. If you're smart, talented, and can stomach the learning curves of starting a new business you're fine. If there's something you don't like about the practice you can fix it cause you're the owner, but emphasis on YOU GOT TO FIX IT. You will have to fire employees, check up on numbers, etc. It's your business.
For me that's fine. Cause if there's a problem I'm the type of guy who'll fix it on the spot, and try to see if there's a better way to handle it, and if so implement it.
ACT teams: If you got a great team you're fine. If not you're screwed. Otherwise like working in a state institution.
Factor in that the above are general guidelines. While most state hospitals aren't exactly up to date environments, a few are. Many universities are on top of getting things fixed quickly, others aren't
Also you could use one of the above to spring off to something bigger and better.
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I’m still early career, so maybe I’m naive but especially in outpatient seems like instead of moving to get a better job, your current job becomes better over time because you get to know your patients well so visits become progressively easier over time.
(This assumes you work in a system that doesn’t increasingly increase your patient load to an eventually unsustainable point.)
(This assumes you work in a system that doesn’t increasingly increase your patient load to an eventually unsustainable point.)
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Yes.
But you may also collect a higher proportion of certain pathology, like cluster B over time. The patients with depression/anxiety typically will remit and either stop the meds/follow up appointments on their own, or they (or you) refer back to their PCP for ongoing refills. This leaves you with a slowly increasing Axis II population. Or you have a higher volume of Stimulant, benzos, Suboxone etc patients that require the closer more frequent follow ups. Or you do more therapy which carves out time of your week. To reduce the rising tide of cluster B, I diagnosis it early, discuss it, educate on it, and continually encourage the importance of DBT. This is good for the patients, actually helps provide symptom relief, and also helps me reduce the intensity of issues that heighten counter transference - a win win for everyone. But if a clinician is the type that documents it but doesn't emphasize DBT or talk about it with their patients, they'll like have a rising tide of this population in their patient panel.
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One of the negatives is dealing with hospital administration. Administrators will question you on multiple things one being putting pts on 1:1s. Admin has no desire to pay extra staff so they will pressure you take people off 1:1s ASAP. Admin will also try to cut corners and enforce silly rules Admin will understaff units to the point where it’s not safe for pts. They will also try to hire brand new staff so they don’t have to pay them more. Recently our private psych hospital started requiring only a high school diploma to work as a counselor. Before the position required a bachelors.
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Good god....
Those where my exact thoughts when I found out.
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I think this is ok to do for inpatient and CL, but don't work outpatient. It's not good for you or the patients, because as soon as you start to get a sense of their patterns and get them to trust you, you have to take off.
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of course, but being a clinician is antithetical to high achievement as it is the lowest rung of the medical ladder, thus this means taking leadership/administrative positions. You have to remember clinical psychiatrist (any physicians really) are serfs largely dependent on their clinical work to generate revenue and increasingly losing control of the means of production. Thus you need to be in managerial positions in order to ascend:
e.g. in academics it would be something like this
medical director --> division chief ---> vice chair ---> chair ---> dean---> vice chancellor --->provost--> chancellor --> university president
note that a chair of department is basically a middle manager and far from the highest rung on the totem poll
for psychiatric hospitals it might be
medical director --> division chief ---> deputy chief medical officer --> chief medical officer ---> President/CEO
for medical hospitals it might be
medical director --> division chief ---> department chief ---> associate chief medical officer --> CMO --> vice president --> executive vice president --> President/CEO
for organized psychiatry it might be
deputy medical/division director - division director --> vice president --> CEO
e.g. for APA or AMA
for politics there are various positions/multiple routes
e.g. mental health commissioner for the state, head of NIMH, medical director of SAMHSA, Assistant Secretary for Mental Health and Substance Abuse for HHS (these positions do not pay well but command enormous respect and as with other political positions often lead to [ethically questionable] financial rewards, consultancies, board directorships and other positions post-politics)
for medical education
associate residency director/clerkship director --> residency director/director of medical student education in psychiatry --> vice chair for education --> DIO --> Dean of UME/GME
there are variety of leadership roles e.g. the former CEO of AAMC Darrell Kirch is a psychiatrist, CEO of ABPN in Larry Faulkner a psychiatrist (laughing all the way to the bank, he can console himself with the bags of money despite being the most reviled psychiatrist amongst his colleagues), and there is a whole alphabet soup of educational organizations that have physician leaders (e.g. ACGME, ACCME, ABMS, NBME, ECFMG)
for private practice
solo practitioner --> President/CEO group practice ---> President/CEO larger group practice ---> President/CEO multi-location group practice (same locale) ---> President/CEO multi-location group practice (across state) --> President/CEO multi-location group practice (multiple states)
there are similar pathways in corrections, state/county jobs, VA, Kaiser etc and of course one can make lateral transfers.
There are also opportunities for enterprising physicians to make it into tech (including EMRs), telepsych, consulting, mediation, pharma and the disability industry (i.e. having a large firm of contracted physicians from multiple specialties performing disability evaluations for SSI, SSDI, C&P, private disability, worker's compensation etc)
e.g. in academics it would be something like this
medical director --> division chief ---> vice chair ---> chair ---> dean---> vice chancellor --->provost--> chancellor --> university president
note that a chair of department is basically a middle manager and far from the highest rung on the totem poll
for psychiatric hospitals it might be
medical director --> division chief ---> deputy chief medical officer --> chief medical officer ---> President/CEO
for medical hospitals it might be
medical director --> division chief ---> department chief ---> associate chief medical officer --> CMO --> vice president --> executive vice president --> President/CEO
for organized psychiatry it might be
deputy medical/division director - division director --> vice president --> CEO
e.g. for APA or AMA
for politics there are various positions/multiple routes
e.g. mental health commissioner for the state, head of NIMH, medical director of SAMHSA, Assistant Secretary for Mental Health and Substance Abuse for HHS (these positions do not pay well but command enormous respect and as with other political positions often lead to [ethically questionable] financial rewards, consultancies, board directorships and other positions post-politics)
for medical education
associate residency director/clerkship director --> residency director/director of medical student education in psychiatry --> vice chair for education --> DIO --> Dean of UME/GME
there are variety of leadership roles e.g. the former CEO of AAMC Darrell Kirch is a psychiatrist, CEO of ABPN in Larry Faulkner a psychiatrist (laughing all the way to the bank, he can console himself with the bags of money despite being the most reviled psychiatrist amongst his colleagues), and there is a whole alphabet soup of educational organizations that have physician leaders (e.g. ACGME, ACCME, ABMS, NBME, ECFMG)
for private practice
solo practitioner --> President/CEO group practice ---> President/CEO larger group practice ---> President/CEO multi-location group practice (same locale) ---> President/CEO multi-location group practice (across state) --> President/CEO multi-location group practice (multiple states)
there are similar pathways in corrections, state/county jobs, VA, Kaiser etc and of course one can make lateral transfers.
There are also opportunities for enterprising physicians to make it into tech (including EMRs), telepsych, consulting, mediation, pharma and the disability industry (i.e. having a large firm of contracted physicians from multiple specialties performing disability evaluations for SSI, SSDI, C&P, private disability, worker's compensation etc)
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I get your point (good one), but just to play devil’s advocate: The monetary value at most of those positions does not increase through just job hopping. Just the opposite. The average program chair in academia has spent decades job hopping. By staying put and building a private practice, I’ll out-earn my past program chair within 5 years of training. They’ve been at it 20+ years job hopping. I could even work at a private practice and out-earn faculty 15 years my senior in year 1 post training while seeing fewer patients. Choosing a more lucrative setting is more valuable than job hopping.
If I want to take the next step, I’ll need to make a big step outside of medicine as you describe. I’d say private practice is more lucrative than president of a large academic center, especially when considering the years to get there. I believe I’ll get there quicker in private practice (realistic for many physicians). To truly move up financially, I’d need an elevated position at a large corporation which would be an unusual jump or I’d need to become CEO of a hospital (also unusual). Getting there typically involves job hopping at lesser paying non-medical positions than private practice hoping to one day get there.
A friend is going the hospital CEO path. In about 5 years, he has steadily taken “promotions” within a large organization. His salary decreases with promotions as he sees fewer and fewer patients. He does receive “stock options” but the entity isn’t public so he only benefits upon a big sale. Today he works longer hours, travels more, etc for less money with the goal of eventually running a large organization. We will see if it pans out. He hasn’t done any job hopping yet, partly because I believe his options are contingent on continued employment. He loses them upon leaving. In 5 years, he hasn’t received any promotions that increase earnings elsewhere though.
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Yep. You might also be in a place where the employees suck. Agree totally. But nice furniture and hotel like lobbies, good coffee. Nice snack-bar.
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Depends. Not uncommon for CEO of a large academic center to earn $600k+ but I'm really channeling where I work and it's more like $1.2M++.
But I agree overall that the small few who make it to leadership positions which pay have also typically spent years working at the usual lower academic salaries.
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1.2 sounds meager? A very select few folks earn an order of magnitude more at the really big places. Not that anyone should ever bet on it, but 10+ is possible. Think of the largest fanciest academic institutions in big cities and check their public tax filings.
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1.2 sounds fantastic, but consider that they earn that after working for 15 - 20 years making 25 - 50% below what they could be making in private practice and suddenly 1.2 million isn't worth it IF you're doing it for the money. Most people in these positions aren't doing it for the money. Some are in it for the prestige and clout, some for the experience, some for genuinely altruistic reasons (cue the skeptics out there).
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I would only want to work in a leadership position in psychiatry if the majority of the employees under me were good. From my experience, except for working at a top academic center, enough attendings I've seen were incompetent and the facility kept them cause they had no one to replace them. The degree was to the point where I'd rather just do private practice and not have to deal with incompetence on that level. This will likely change because psychiatry is becoming more competitive but the current improved trend won't be seen in real clinical care for several years.
I likened it to Michael Jordan joining the Utah Jazz. MJ was possibly the best basketball player of all time but even he couldn't elevate the Utah Jazz, and that wasn't his fault. It was theirs.
Last academic place I worked (and it WAS NOT U of Cincinnati, I'm mentioning this cause many know I worked there and might unfairly think I'm talking about them) the head of the department was one of the best leaders and psychiatrists I've ever known, but the university as a whole was so inept he couldn't do much to fix it.
I likened it to Michael Jordan joining the Utah Jazz. MJ was possibly the best basketball player of all time but even he couldn't elevate the Utah Jazz, and that wasn't his fault. It was theirs.
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The presidents of BWH, MGH, and MD Anderson all make in the 1-2M range. Maybe there are bigger/richer systems you have in mind that pay 10x that?
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Second that notion!
Disagree with that notion, other more competitive specialties still suffer same concept. I believe the Peter Principle is at play.
Who knows how quality of care will change but I know most med students see psych as a "lifestyle specialty". They all think that they will have their own cash pay PP and make the big bucks.
I mean you're right these three things are definitely pluses.
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can you give examples of attendings being incompetent? Do you mean not going above and beyond for their patients or actual substandard/malpractice incompetence by an attending?
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There aren't a ton but there are a few in the 10ish range that I know of and several well above $2 at last check:
Last 990s, for highest paid employees usually 2017, several MDs
Partner's: over $5 million
NYP: over $7 million
NYU Langone: over $10 million
Mount Sinai: over $12 million
Northwell: over $4 million
Banner health: almost $9 million
Kaiser: over $15 and over $6 million
Ascension health: over $5 million
UPMC: over $6 million
CHOP: over $13 million
For profit:
HCA holdings: over $17 million
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I can speak to UPMC - Jeff Romoff is definitely making big bucks but he is not head of an academic medical institution, he is the CEO of a ginormous hospital system spanning 40+ hospitals that has a tiny slice that happens to have academic ties and/or is involved in resident training.
Relevantly, the system was initially started by a psychiatrist
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I think you are the only person here who’s saying things I can remotely identify with.
People are deceived by high CEO salaries. First of all, CEOs only get paid more if they are managing large organizations, and their salary get incrementally larger as the size of the organization become larger. This means that it’s harder and harder to become CEO at larger organizations. So job hopping in and of itself would not allow you to just randomly become a CEO of a large hospital.
As a rank and file physician, it’s vastly easier in this field to make more money if you operate OUTSIDE of the large organizational model and OWN your practice. This aspect can not be underemphasized, and yet most people don’t get it. It’s not rare in private practice to gross 500-1M. It’s actually very very rare to be a hospital CEO and get the same income. Your usual community hospital CEOs get paid like garbage, manage mundane nonsense and have complete garbage jobs.
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