How did you feel after leaving academia for private practice?

[neolandrover]

---

Members don't see this ad.

I currently am junior faculty at a major academic institution, making above the AAMC average for my rank (although not nearly as much as I could in PP). I do a mix of inpatient/outpatient, small amount of neuromodulation, and teaching. Compared to my colleagues, I probably have a better work/life balance in terms of the mix of things that I do. That being said, I still cover several weeks and do call throughout the year. Lately, the acuity has started to be quite draining and now a few years out from residency, I have come to extremely detest taking call or working weekends. While it would have been nice to have built a long term academic career, I don't think this is sustainable for me.

I am strongly considering leaving for private practice (joining an established practice), and weighing cash only vs. insurance based practices. There are plenty of opportunities in my area.

I'm curious those of you that have left academia for PP, especially in the last 5 years, how did you feel afterwards regarding:
-Salary
-Work/life balance, leaving work at work
-Ability to take vacation
-Difficult patients in PP
-Control over the way you want to practice
-Pt hours or # of pts you see per day
-Ultimately, did you feel that for you that PP was better?

Thanks very much in advance for your thoughts!

 

[dl2dp2]

- salary - much better
- WLB - PP has some coverage, but given how much you get paid, it's not even in the same league
- much better
- you'll have difficult patients in PP or in academia, and PP tends to be fewer
- control: not even in the same league
- way fewer
- PP is much MUCH better if you only care about clinical work

Academia is not worth as a clinician it unless you specifically want to do education, research, administration, etc.

 

[clausewitz2]

I still do volunteer resident teaching on topics that interest me a few times a year, so I feel like I still get at least a taste of the bit of academia that I'm mostly interested in.

Salary - I'm sure you can find some employed position out there that will stiff you as hard as the typical academic institution but you will have to go looking

WLB - if you are bad at setting limits without a protective screen of nurses between you and the patient, PP could eat your life. If you are good at saying no to people and maintaining those limits, you don't have to so much as glance at your email over the weekend.

Vacation - if you are strictly eat what you kill, this can be tricky. Salaried positions of course you can maximize your PTO and in fact would be somewhat foolish not to, even if you had no particular plans. In PP a day off means your earnings take a hit. You can still make much more than academia even with days off, but when I was calculating salary equivalents I always assumed working 46 weeks out of the year. You do have the ability to make up for days off by running a fuller schedule around the time you take vacation once you're full; the rest is even sweeter if you are coming off of a super busy time

Difficult patients - again, limit-setting is key. I think honestly the problem you are more likely to run into are patients who are difficult because you click too well with them, to the point you can start missing clinically important stuff because you lose your objectivity

Control - I do what I want, you're not my dad

# of patients per day - again, when full, how much do you want to make that day? It helps to have a robust no-show fee. My days can vary between 8 and 16, modal is probably 12-13, but I still take 90 minutes for lunch. Also don't work 5 days a week.

PP absolutely superior for me in my life to anything more structured or that requires me to do what I'm told.

 

[Merovinge]

Difficult patients - again, limit-setting is key. I think honestly the problem you are more likely to run into are patients who are difficult because you click too well with them, to the point you can start missing clinically important stuff because you lose your objectivity

This is what I see with my peers doing cash pay practices. They tend to attract similar patients to their own SES, ethnicity, religious affiliation, etc and even in large cities some of these groups can be a small world. I think this is a tougher problem with people who are so nice to you and always pay their bills upfront as they will be more common than the demanding/***hole crowd.

 

[dl2dp2]

This is what I see with my peers doing cash pay practices. They tend to attract similar patients to their own SES, ethnicity, religious affiliation, etc and even in large cities some of these groups can be a small world. I think this is a tougher problem with people who are so nice to you and always pay their bills upfront as they will be more common than the demanding/***hole crowd.

What's wrong with patients who are so nice to you and always pay their bills upfront?

I'm confused. Shouldn't EVERYONE be nice to everyone else and pay their bills on time?

There are scenarios where you might keep a patient in treatment too long when they don't need it because the whole experience is "too pleasant" for everyone involved, but if you are aware of this dynamic and make the frame very clear ("this is not symptoms driven, you are in remission, this is now insight-driven, etc") I don't see how this is clinically problematic.

 

[randomdoc1]

What's wrong with patients who are so nice to you and always pay their bills upfront?

I'm confused. Shouldn't EVERYONE be nice to everyone else and pay their bills on time?

There are scenarios where you might keep a patient in treatment too long when they don't need it because the whole experience is "too pleasant" for everyone involved, but if you are aware of this dynamic and make the frame very clear ("this is not symptoms driven, you are in remission, this is now insight-driven, etc") I don't see how this is clinically problematic.

That's why I have no guilt in PP. I busted my rear off so much of my life. I'm not sacrificing more for audiences who willingly continue to be entitled, nasty, make you work for nothing, etc. I like working with people who are motivated to change. And patients seeing us as individuals who need to earn a living, is progress too. Because they consider others and can effectively navigate awkward conversations. For those who have less means, that's what Medicaid and ACA plans as well as community outreach resources are for. We're not their parents. Plus, not pushing individuals sufficiently to use resources and find sustainable long term plans only entrenches more chaos. /rant.

 

[clausewitz2]

What's wrong with patients who are so nice to you and always pay their bills upfront?

I'm confused. Shouldn't EVERYONE be nice to everyone else and pay their bills on time?

There are scenarios where you might keep a patient in treatment too long when they don't need it because the whole experience is "too pleasant" for everyone involved, but if you are aware of this dynamic and make the frame very clear ("this is not symptoms driven, you are in remission, this is now insight-driven, etc") I don't see how this is clinically problematic.

The problem comes when that turns into you not wanting to acknowledge unpleasant realities or facts about their situation, or don't ask questions about subjects they find uncomfortable that are extremely relevant to actually effective treatment.

That said I do like working with folks with OCD as they tend to be extremely conscientious if nothing else. If they agree to do something for their treatment they are almost always actually going to do it.

 

[randomdoc1]

The problem comes when that turns into you not wanting to acknowledge unpleasant realities or facts about their situation, or don't ask questions about subjects they find uncomfortable that are extremely relevant to actually effective treatment.

That said I do like working with folks with OCD as they tend to be extremely conscientious if nothing else. If they agree to do something for their treatment they are almost always actually going to do it.

Well, we're supposed to be the experts about transference and counter transference right? Although I know there's this conflict of interest regarding finances, I try to be assertive about these uncomfortable matters anyways. I tell the patient, it's my job. And being a good physician to them does not always equate to what is comfortable. Medicine can taste bitter, surgery can hurt, but we're physicians and have a patient to look out for. I've had some similar discussions with long time patients who steadily ask why can't they just take that xanax a little more often. And I point out, well, that tells me this is a symptom. We need to go after the underlying issue and xanax is not a solution for sure.

 

[clausewitz2]

Well, we're supposed to be the experts about transference and counter transference right? Although I know there's this conflict of interest regarding finances, I try to be assertive about these uncomfortable matters anyways. I tell the patient, it's my job. And being a good physician to them does not always equate to what is comfortable. Medicine can taste bitter, surgery can hurt, but we're physicians and have a patient to look out for. I've had some similar discussions with long time patients who steadily ask why can't they just take that xanax a little more often. And I point out, well, that tells me this is a symptom. We need to go after the underlying issue and xanax is not a solution for sure.

Oh, I agree 100% that you do have to make people uncomfortable not infrequently in our line of work. I was just saying that it can be harder for some people to do this with people that under other circumstances they'd be friends with.

 

[Merovinge]

Well, we're supposed to be the experts about transference and counter transference right? Although I know there's this conflict of interest regarding finances, I try to be assertive about these uncomfortable matters anyways. I tell the patient, it's my job. And being a good physician to them does not always equate to what is comfortable. Medicine can taste bitter, surgery can hurt, but we're physicians and have a patient to look out for. I've had some similar discussions with long time patients who steadily ask why can't they just take that xanax a little more often. And I point out, well, that tells me this is a symptom. We need to go after the underlying issue and xanax is not a solution for sure.

I have zero doubt you do this well, but there are certainly concerns that arise with confrontation avoidant docs (and let's be honest, there are a large number of psychiatrists falling into that basket) are also see patients who are they like and or do like as individuals. It's easier to hold firm boundaries when you internally feel they are needed and this is certainly different if it's someone you also see at your country club. I'm not saying anyone should avoid these situations, but it does take a significant skill and comfort level to traverse and still provide the best clinical practice.

 

[randomdoc1]

I have zero doubt you do this well, but there are certainly concerns that arise with confrontation avoidant docs (and let's be honest, there are a large number of psychiatrists falling into that basket) are also see patients who are they like and or do like as individuals. It's easier to hold firm boundaries when you internally feel they are needed and this is certainly different if it's someone you also see at your country club. I'm not saying anyone should avoid these situations, but it does take a significant skill and comfort level to traverse and still provide the best clinical practice.

I like to fantasize about the next wave of psychotherapy/mental health practices. There was the rise of CBT, then pharmacotherapy, DBT. So many modalities that have changed practice forever. I also like to joke that maybe the next wave will come out of this clinic and we'll be in many text books. The randomdoc1's module of 2x4 therapy. It's rough. But it's fast, low cost, in your face, memorable and damn effective. lol

 

[G Sheb]

I have zero doubt you do this well, but there are certainly concerns that arise with confrontation avoidant docs (and let's be honest, there are a large number of psychiatrists falling into that basket) are also see patients who are they like and or do like as individuals. It's easier to hold firm boundaries when you internally feel they are needed and this is certainly different if it's someone you also see at your country club. I'm not saying anyone should avoid these situations, but it does take a significant skill and comfort level to traverse and still provide the best clinical practice.

Just adding to the point, as a psychiatrist there should be limits on how much 'liking' a patient should guide your treatment.
What if they come from a different background? What if they present in an 'unlikable' way? (which could be part of the psychiatric presentation). Should we turn them away because they are more 'difficult'?
Obviously there are situations when treatment cannot progress, but there is an ethical issue here in turning a patient away who's unlike us, who can't pay as much, who is perhaps not as likeable as we want them..etc.

 

[Stagg737]

It's interesting to me that people are saying the number of patients they see per day in PP is less than in academia. I'm a new attending, but pretty much every academic position I looked at was fewer patients that in PP and in some instances far fewer. Is it common in academia to carry a large inpatient load or be seeing a ton of outpatients in the clinic? Asking because this didn't seem to be the case at all with the academic positions I looked into...

 

[calvnandhobbs68]

It's interesting to me that people are saying the number of patients they see per day in PP is less than in academia. I'm a new attending, but pretty much every academic position I looked at was fewer patients that in PP and in some instances far fewer. Is it common in academia to carry a large inpatient load or be seeing a ton of outpatients in the clinic? Asking because this didn't seem to be the case at all with the academic positions I looked into...

It likely comes down to number of patients for the same amount of pay. The reason people end up seeing more patients or working more hours in PP is because they want to make more money. In academics or similar employed positions, your pay isn't as directly tied to the amount of patients you see per day or billing. For instance, I could probably work around 20 hours a week and make about the same amount (even taking benefits into consideration) as 1.0 FTE would be worth at where i did fellowship.

 

[Stagg737]

It likely comes down to number of patients for the same amount of pay. The reason people end up seeing more patients or working more hours in PP is because they want to make more money. In academics or similar employed positions, your pay isn't as directly tied to the amount of patients you see per day or billing. For instance, I could probably work around 20 hours a week and make about the same amount (even taking benefits into consideration) as 1.0 FTE would be worth at where i did fellowship.

Right, but DL2 said they are seeing "way fewer" patients in PP than in academia which seems backwards to me if we're comparing 1.0 FTE in each setting.

 

[dl2dp2]

Oh, I agree 100% that you do have to make people uncomfortable not infrequently in our line of work. I was just saying that it can be harder for some people to do this with people that under other circumstances they'd be friends with.

I see what you are saying but in psychiatry clinical practice in PP means you can do psychotherapy as you choose. This is an unique aspect of this field.

Number of patients in PP is more highly related to control of the practice in this field.

 

[splik]

Right, but DL2 said they are seeing "way fewer" patients in PP than in academia which seems backwards to me if we're comparing 1.0 FTE in each setting.

20 hours is often full time for PP. Most clinician educators have more than that for full time. Also most people in academics aren't doing therapy so by the numbers you would be seeing way fewer pts in a cash therapy focused practice.

 

[clausewitz2]

I see what you are saying but in psychiatry clinical practice in PP means you can do psychotherapy as you choose. This is an unique aspect of this field.

Number of patients in PP is more highly related to control of the practice in this field.

Oh yes, i very much am on the same page. If I get someone new who could benefit from a therapy modality I'm trained in and want to work with them, I can decide to be their therapist. If I'm too full to make it work, I don't.

 

[dl2dp2]

Right, but DL2 said they are seeing "way fewer" patients in PP than in academia which seems backwards to me if we're comparing 1.0 FTE in each setting.

I see what you are saying but in psychiatry clinical practice in PP means you can do psychotherapy as you choose. This is an unique aspect of this field.

Number of patients in PP is more highly related to control of the practice in this field.

 

[whopper]

The 2 regrets I have about leaving academia are 1) working with some of the best people in the field and this is not typical in all of academia. You have to work at one of the better places to work with the best. Along with this comes all of the intellectual brain candy that comes along with it. 2) Working as a team member in what could be a great team. Private Practice you work with less people.

I've mentioned this. I recommend everyone work in academia at least a few years after graduation unless the academic institution is not worth it. I did feel I plateaued in what it could offer me especially when hearing a top mind tell me of his out of the box techniques and I've already heard it, used it, and at that point then knew it. At that time and because the last place I worked at I didn't find the experience enjoyable I exited out.

Private Practice does have it's issues that make it not for everyone. Some people can't do their taxes. Yes of course you get an accountant but you need to have some skill in this to organize to present to the accountant. Some people don't know how to handle hiring and firing employees. You can't do stuff like this you shouldn't be in private practice.