Inpatient Psych

[Ellomate]

Hey Y'all.
I'm finishing up my MS3 and just some lingering questions on pursuing psych.
I really didn't like any of my rotation except Psych & Anesthesia. Obviously very different but I always enjoyed procedures (but didn't like having people scream at my ear reducing fractures or putting stitches in kids in the ER, and hate surgery with a passion; but anesthesia allowed me to intubate and put lines while they are asleep. Also can advance with cardiac procedures if desired)

I also don't think I can handle the outpatient set up of 45 min follow up and 90 mins new intake.
I'm in my last week of FM rotation and listening to some people go on-and-on has been so exhausting...
I also took this as a sign that maybe psych is not for me, and I went to a crisis mode end of 3rd year since I need to decide ASAP. This is a very stressful time...

My inpatient psych experience had 3 providers (2 doc + 1 NP) covering 30 patients (10 each). The NP covered the "open" side, meaning higher functioning people with less acute issues. They began their day at 9pm and finished around 4pm and hung around till 5pm.

My questions are as follow:
(preference to the northeast region)

1. Typical schedule in inpatient
2. What time do inpatient docs go in and get out?
3. How common is it to leave at 1pm?
4. Do they normally take 2nd FT job Outpatient? Can you go to a 2nd inpatient job in the afternoon?
5. Any call responsibilities? Weekends?
6. Are you able to take longer vacations? Who will cover for you? My hospital, if one called out, the other had to see 20 patients. So I don't think they take long stretch of breaks.
7. Concerned about assault?
8. We kept some involuntary patients and they were not happy. Worried about seeing them in the street while you're out with your family?
9. Do you really make a difference in patients life or just stabilize and ship?
10. How do you take care of your mental health? Do u feel burned out walking out?
11. What is the compensation range for inpatient Doc in the the NORTHEAST?
12. Do you prefer higher base salary, or lower base with RVU bonus?
13. If on RVU bonus, does this keep you from taking vacation?

Thank you for taking your time to answer and ease my anxiety...
I am burned out to the max and just holding my breath until i graduate. It's been so suffocating and difficult the last few months with the stress of rotation + studying every night. My body is debilitating and my soul crushed little more each day...
I'm sure you all understand the perspective of a 3rd year med student.
Much appreciated your insights

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[Merovinge]

If you can only see yourself doing inpatient psychiatry and have another specialty you are interested, I would lean towards the other specialty. There is a lot of outpatient and psychotherapy training in psychiatry training and if you feel like listening to others is draining I would say this is a great time to became a gas master. Anesthesiology usually pays better than psych and it can shift work easier if you want long blocks of time off.

 

[Celexa]

If you like psychiatry regardless of what else you like, psychiatry is the best specialty.

If you don't like talking to people, you don't like psychiatry.

It sounds like you mostly liked your psychiatry clerkship bc the scheudle wasn't brutal. That's OK but it's not a reason to spend your life doing it.

Inpatient is only a small slice of psychiatry and very non representative of the majority of psychiatric work.

From what you wrote I don't recommend psych for you, but it might be a good idea to do a fourth year elective to clarify your thoughts. Psych electives tend to be very useful no matter what you end up going into anyway.

 

[comp1]

Oh do I relate to this MS3!! I really, really disliked the vast majority of my 3rd year and psychiatry, while I did like it...but to be quite honest, choosing it really was slightly more me hating everything else a great deal. And yes, for me it was also the outpatient that I didn't absolutely love about psych. Every day on inpatient was exciting and you always had complete schedule flexibility. First and foremost, literally all of these items are going to EXTREMELY variable and you're going to have to decide which factors are most important to you when you get to job interviews. Do LOTS of moonlighting to figure that out. So on to the specifics!

There is no typical schedule! Some people will be 1099's and just leave when they see all of their patients. Most VA and academic employees will have a set daily time, for example on my unit it is usually 8-4:30, but we have some providers who do four days a week 7-5:30 or some other weird combination that adds up to 40 hours. I think the salaried schedule is a better deal for everybody as you're available for your patients when they need you, like when they have court or have an afternoon medication question. Leaving at 1 PM would be for 1099's or some sort of very part time salaried job. In general, trying to cover two hospitals sounds like crazy making. Just get a salaried job at one hospital. You'd have to get the nurses and social workers onboard with your afternoon rounding if you wanted to do that. Outpatient in the afternoon is more common if you have to take a 1099 job.
Call is a part of inpatient generally and you're generally compensated for it. On my team, we do four weeks a year where we serve as back up to an in house NP overnight and come in on the weekends to see just the patients that need immediate attention. It's fair and equitable. As an inpatient doctor, it's nice to be able to follow your people every day. There are other systems that are 7 on/7 off, but they are much, much rarer in psychiatry. Yes, call generally involves working weekends and holidays. The amount of staff you have is what determines issues like vacation. For example, we have 3.5 psychiatrists and an NP for a 16 bed unit. That sounds like A LOT, but when you consider that 1-2 of them will be on vacation or sick at any given time, it seems more reasonable. You want a setting like that, not like one where you rotated.
Assault is always possibility, but rare. Statistically, nursing is a heck of a lot more likely to be assaulted, but sure it could happen to you. It hasn't happened to me. Be aware of your surroundings and always review a chart before meeting with a patient. I live in an urban core and see a lot of my patients out on the street. You know what? It's been my experience that the ones who were upset with being on the unit want NOTHING to do with me and certainly wouldn't come up to me as they are worried about being rehospitalized. Occasionally I do have patients asking to be rehospitalized from the street, but they generally don't need that level of care and I'll direct them to more appropriate housing resources.
Don't make a dichotomy between stabilizing and "making a difference." Stabilizing DOES make a difference, particularly for society. That said, you do need to keep aware of your limitations on an inpatient unit or you will burn out. Ultimately, change comes from the patient, not you. You can offer the resources, you cannot force people to use them. That said, often patients do eventually decide to use them after enough psychiatric admissions, at least half do.
Your own mental health is going to be an issue anywhere in medicine and very few job opportunities offer a better work life balance than inpatient psych. You'll be good. Get in your own therapy while in residency and stay in it. Make sure you have a really good team on your inpatient unit, preferably one that you even do things like go out to a happy hour with.
I don't really know about the Northeast. It'll probably be around $250k, but there's so much variation...I'm not sure if an average is even helpful. Take the higher base salary. You don't want to ever give a patient a chance to even argue that you're keeping them there to make money off them.

 

[splik]

In addition to inpatient, you could also consider emergency psych, C-L, PHP, IOP, nursing homes, residential treatment programs, correctional psychiatry, interventional psychiatry (e.g. ECT, TMS), detox facilities, or community mental health (e.g. working for an ACT team or homeless outreach etc where you don't have pts scheduled in the typical way). It is not just inpatient v outpatient, and most outpatient is not 90 minute news and 45min follow ups (which is rare in employed non-private practice jobs for adult psychiatry).

1. Typical schedule in inpatient

There is no typical schedule. it will depend entirely on the set up. However in addition to seeing patients, you will likely attend a multidisciplinary treatment team meeting, may have to attend court hearings, have to do utilization review calls (i.e. asking insurance for more days), and may have to respond to emergencies and things related to restraints and seclusion etc.

1. What time do inpatient docs go in and get out?

You should anticipate a typical schedule is 8-5. You may be able to negotiate start and end times. In my area, there are lots of 7am-11pm Inpt jobs where you basically do shift work but work fewer days (e.g. 9 days a month). If you just contract with the hospital and bill yourself you can come in and leave as you please.

1. How common is it to leave at 1pm?

It's not common but entirely dependent on the set up. In general, if you work part-time, you will be paid on a pro rata basis (i.e. if you work 20hrs, expect to paid accordingly unless you are fee for service). Some cushy salaried jobs may allow you to leave when the work is done but usually you will be responsible for putting in orders, answering nursing calls, and may have to do evals for restraints/seclusion (depending on type of unit) even after rounding on your pts. Also depends on the volume of patients which could be as low as 6 or as high as 30. 8-11 is considered good but many jobs have higher pt volumes.

1. Do they normally take 2nd FT job Outpatient? Can you go to a 2nd inpatient job in the afternoon?

If you have a full time job it is unlikely you would work another 2nd full time job. People do this on occasion but it's not common. More common is for some one to a part-time job and another PT outpatient job. Or for someone who have a FT inpt gig and then have a private practice. Again, the set up will be dependent on the job itself.

1. Any call responsibilities? Weekends?

You can bet that if is a typical 8-5 job then you might be expected to have call responsibilities. However this is negotiable and increasingly moonlighters cover this. If you work a hospitalist/shift-work system there is no call but you may be asked to do weekends sometimes.

1. Are you able to take longer vacations? Who will cover for you? My hospital, if one called out, the other had to see 20 patients. So I don't think they take long stretch of breaks.

Coverage is the issue. If employed, you will have standard 4-5 weeks vacation a yr. It might be hard to take more than a week off in advance. Yes, typically someone will have to pick up your patients when you are away, and you would do the same. However there are some set ups as a contractor where you can do this. or if you do locums you can take as much time off as you like in between (unpaid of course).

1. Concerned about assault?

The nurses and techs take the brunt of this. Also depends on the unit. Something to consider but at the bottom of the list unless you're working at a state hospital or somewhere with lots of dangerous pts.

1. We kept some involuntary patients and they were not happy. Worried about seeing them in the street while you're out with your family?

No.

1. Do you really make a difference in patients life or just stabilize and ship?

This concern seems incompatible with leaving at 1pm and running off to another job. You have to put in time and effort to make a difference in your patients' lives. Most inpt is about stabilization and not treatment. But yes you can make a substantial difference in patient's lives in the right job. but most inpatient psych is awful and not set up to help pts. However in the right setting it can be satisfying to help people through crises and see patients with

1. How do you take care of your mental health? Do u feel burned out walking out?

Have a full life. spend time w/ family and friends. indulge your hobbies. Travel. Have your own therapy. The nice thing about inpt is you can leave it on the unit. Once you're done, no one should be calling you, no refills, prior auths, patients calling in crisis etc.

1. What is the compensation range for inpatient Doc in the the NORTHEAST?

Compensation in the northeast is lower than anywhere else, but variable. Typically 200-300k.

1. Do you prefer higher base salary, or lower base with RVU bonus?

You have to do the math and figure it out. The ideal is high salary, low wRVU target, high conversion factor for bonuses. Personally, I am opposed to the whole wRVU thing but some people love it. Just pay me a salary, or by the hour, or do my own billing, or % collections thank you very much.

1. If on RVU bonus, does this keep you from taking vacation?

It could, if you get addicted to making money. But you have to do the math and factor that into your compensation (i.e. you should calculate your pay based on working 46 weeks per year for example). This is no different from private practice or locums where you don't get paid if you don't work.

 

[Ellomate]

There is a lot of outpatient and psychotherapy training in psychiatry training and if you feel like listening to others is draining I would say this is a great time to became a gas

If you don't like talking to people, you don't like psychiatry.

I don't mind talking to people. I have some youth counseling background prior to medical school. But these kids were high functioning without ADHD, schizo, bipolar, and such.
EXAMPLES
(1) I had a pt in FM who was so tangential. I asked if she had trauma to her finger and she didn't stop talking about the dinner she had where she met her son-in-law and how great he was. Even with multiple redirection should couldn't just answer my questions appropriately... Left the room so exhausted ...
(2) A 30 year old female borderline girl came in for follow up of a recent pneumothorax hospital course. Soon found out she had 2 kids and 9 miscarriages. She also had plethora of health issues and her mood was so labile. It was tough connecting with her and sympathizing for her at a certain point.
Like I enjoy conversing with people, and I also do find psych pathologies fascinating. Sometimes, however, talking with psych patients really take a toll and I'm afraid that this is a SIGN for me to not go into it. Did you guys click with psych patients as a med student? Could you not see yourself doing anything else but psych? Did you not have a time where you felt the same way and just found the tangential speech a drag? What was about psych that drew you in while as a med student?

I really, really disliked the vast majority of my 3rd year and psychiatry, while I did like it...but to be quite honest, choosing it really was slightly more me hating everything else a great deal. And yes, for me it was also the outpatient that I didn't absolutely love about psych

You completely understand me. I'm glad there are others out there who can identify with my experience. It feels so taboo to tell other med students that I really didn't enjoy anything... Like some of these kids are chasing their "passions" and I'm here trying to land something I'll be able to tolerate. Because of this, I'm in a state where I am counting my losses and just doing something that'll give me more time at home with family, hobbies, and friends. I love guitar (hope I can go into producing music), photography, city life, pulling good espresso and frothing the perfectly textured milk for latte. I have so many things I enjoy outside of medicine that I feel like, at this point, I want to find majority of my joy outside of my job. What was the deciding factor that confirmed your decision on pursuing Psych? If want to talk more in dept with personal reasons, I'd love to talk via PM!

Some people will be 1099's and just leave when they see all of their patients.

1. How common is it to leave at 1pm?

It's not common but entirely dependent on the set up

What is the majority? I've read extensively on the psych forum on SDN & Reddit and it seems like A LOT of inpatient docs leave around 1-3pm.


At this point, I'm at a place where my motto is "don't live to work, but work to live". I'm having a difficult time balancing between [Passion/Joy/Genuine heart & Just a job/Salary]

 

[painballer27]

What is the majority? I've read extensively on the psych forum on SDN & Reddit and it seems like A LOT of inpatient docs leave around 1-3pm.

Yeah I also want to know where the truth lies. Most of the time I see people talk about ~250k for inpatient psych, but every once in a while I'll see someone post about pulling in significantly higher numbers 4-600k+ inpatient working 5-6 hours a day and describe it like its a common occurrence among psychiatrists. Is it really common? How feasible is it to find something like this? Whats the difference between docs who make this kind of money vs. those who don't?

 

[mistafab]

Did you guys click with psych patients as a med student? Could you not see yourself doing anything else but psych? Did you not have a time where you felt the same way and just found the tangential speech a drag? What was about psych that drew you in while as a med student?

As a med student it was hit or miss if I "connected" with the patient. It wasn't really the goal to connect with people on inpatient psych though. The point was to always be a professional, stay safe, and get what you needed. I was able to see my self in many other areas of medicine as I generally enjoy life and enjoy work. I think most people find tangential speech a drag at first, but as you get better you have more tools at your disposal to steer things into productive areas.

Really what drew me into psych was that when I left the hospital I found it still stimulating to think about the cases. Whereas with general surgery or urology, I left all my thinking after leaving the hospital, and had no time during my free time where I thought about it at all. Yes, the procedures and job was cool, but the subject matter was just boring (penises, kidneys, livers, and guts - who cares?). That in the end made my decision to go into psych very easy. Glad I did, and it has been very rewarding in residency.

 

[psyspy]

Yeah I also want to know where the truth lies. Most of the time I see people talk about ~250k for inpatient psych, but every once in a while I'll see someone post about pulling in significantly higher numbers 4-600k+ inpatient working 5-6 hours a day and describe it like its a common occurrence among psychiatrists. Is it really common? How feasible is it to find something like this? Whats the difference between docs who make this kind of money vs. those who don't?

Still a med student but from what I’ve seen geographics influence it substantially for psych. Those kind of latter figures/jobs are much more likely to be in the southeast/midwest/southwest than anywhere else

 

[psyspy]

In addition to inpatient, you could also consider emergency psych, C-L, PHP, IOP, nursing homes, residential treatment programs, correctional psychiatry, interventional psychiatry (e.g. ECT, TMS), detox facilities, or community mental health (e.g. working for an ACT team or homeless outreach etc where you don't have pts scheduled in the typical way). It is not just inpatient v outpatient, and most outpatient is not 90 minute news and 45min follow ups (which is rare in employed non-private practice jobs for adult psychiatry).

1. Typical schedule in inpatient

There is no typical schedule. it will depend entirely on the set up. However in addition to seeing patients, you will likely attend a multidisciplinary treatment team meeting, may have to attend court hearings, have to do utilization review calls (i.e. asking insurance for more days), and may have to respond to emergencies and things related to restraints and seclusion etc.

1. What time do inpatient docs go in and get out?

You should anticipate a typical schedule is 8-5. You may be able to negotiate start and end times. In my area, there are lots of 7am-11pm Inpt jobs where you basically do shift work but work fewer days (e.g. 9 days a month). If you just contract with the hospital and bill yourself you can come in and leave as you please.

1. How common is it to leave at 1pm?

It's not common but entirely dependent on the set up. In general, if you work part-time, you will be paid on a pro rata basis (i.e. if you work 20hrs, expect to paid accordingly unless you are fee for service). Some cushy salaried jobs may allow you to leave when the work is done but usually you will be responsible for putting in orders, answering nursing calls, and may have to do evals for restraints/seclusion (depending on type of unit) even after rounding on your pts. Also depends on the volume of patients which could be as low as 6 or as high as 30. 8-11 is considered good but many jobs have higher pt volumes.

1. Do they normally take 2nd FT job Outpatient? Can you go to a 2nd inpatient job in the afternoon?

If you have a full time job it is unlikely you would work another 2nd full time job. People do this on occasion but it's not common. More common is for some one to a part-time job and another PT outpatient job. Or for someone who have a FT inpt gig and then have a private practice. Again, the set up will be dependent on the job itself.

1. Any call responsibilities? Weekends?

You can bet that if is a typical 8-5 job then you might be expected to have call responsibilities. However this is negotiable and increasingly moonlighters cover this. If you work a hospitalist/shift-work system there is no call but you may be asked to do weekends sometimes.

1. Are you able to take longer vacations? Who will cover for you? My hospital, if one called out, the other had to see 20 patients. So I don't think they take long stretch of breaks.

Coverage is the issue. If employed, you will have standard 4-5 weeks vacation a yr. It might be hard to take more than a week off in advance. Yes, typically someone will have to pick up your patients when you are away, and you would do the same. However there are some set ups as a contractor where you can do this. or if you do locums you can take as much time off as you like in between (unpaid of course).

1. Concerned about assault?

The nurses and techs take the brunt of this. Also depends on the unit. Something to consider but at the bottom of the list unless you're working at a state hospital or somewhere with lots of dangerous pts.

1. We kept some involuntary patients and they were not happy. Worried about seeing them in the street while you're out with your family?

No.

1. Do you really make a difference in patients life or just stabilize and ship?

This concern seems incompatible with leaving at 1pm and running off to another job. You have to put in time and effort to make a difference in your patients' lives. Most inpt is about stabilization and not treatment. But yes you can make a substantial difference in patient's lives in the right job. but most inpatient psych is awful and not set up to help pts. However in the right setting it can be satisfying to help people through crises and see patients with

1. How do you take care of your mental health? Do u feel burned out walking out?

Have a full life. spend time w/ family and friends. indulge your hobbies. Travel. Have your own therapy. The nice thing about inpt is you can leave it on the unit. Once you're done, no one should be calling you, no refills, prior auths, patients calling in crisis etc.

1. What is the compensation range for inpatient Doc in the the NORTHEAST?

Compensation in the northeast is lower than anywhere else, but variable. Typically 200-300k.

1. Do you prefer higher base salary, or lower base with RVU bonus?

You have to do the math and figure it out. The ideal is high salary, low wRVU target, high conversion factor for bonuses. Personally, I am opposed to the whole wRVU thing but some people love it. Just pay me a salary, or by the hour, or do my own billing, or % collections thank you very much.

1. If on RVU bonus, does this keep you from taking vacation?

It could, if you get addicted to making money. But you have to do the math and factor that into your compensation (i.e. you should calculate your pay based on working 46 weeks per year for example). This is no different from private practice or locums where you don't get paid if you don't work.

Regarding the first question, is it possible for a psychiatrist to take, diagnose, and manage behavioral neuro patients as well (dementia, Alzheimer’s, etc)?

 

[Taddy Mason]

Regarding the first question, is it possible for a psychiatrist to take, diagnose, and manage behavioral neuro patients as well (dementia, Alzheimer’s, etc)?

Geri psych

 

[psyspy]

Geri psych

Do Geri psychs review brain CTs/MRIs in that behavioral neuro setting?

 

[Taddy Mason]

Do Geri psychs review brain CTs/MRIs in that behavioral neuro setting?

They can order them if indicated and go through the images (as with any imaging study) but the formal read is going to come from radiology. Neurologists will have more training in reading imaging but even then they won’t be the ones doing the formal read.

 

[comp1]

In general you're going to spend a great deal of time trying to keep dementia off your inpatient psych unit unless you have a very specialized unit. As an inpatient psychiatrist, you're likely spending the most amount of time you're going to spend on direct patient interactions now as a medical student. You should not be spending so much time with a severely tangential patient that it actually drains you, there is no clinical benefit to that. I fully understand it can be hard as a med student to both figure out how long you need to stay and how to actually get away from a highly disorganized or personality disordered patient, but I promise you figure it out with practice. Radiology is not yet the domain of psychiatry and it's not super likely to become so in any of our careers (thank goodness, I hate anatomy). You'll rely on radiologist reads occasionally to rule out non-psych causes of presentations, but outside of C/L, even that will be rare. Regarding these $600k jobs...don't trust everything you read. There's some prison jobs and horrible locations that pay a bit more than $250k, but $400k is really stretching reality for the vast majority of salaried jobs. Of course, non-salaried jobs where you provide poor care and see way too many patients, the sky's the limit.

 

[splik]

Regarding the first question, is it possible for a psychiatrist to take, diagnose, and manage behavioral neuro patients as well (dementia, Alzheimer’s, etc)?

I'm a neuropsychiatrist so I do see pts with dementia and other neuropsychiatric syndromes but not typically on inpatient psychiatry. Most psych units exclude pts with dementia, TBI, ID, and other neuropsychiatric disorders. Often if these pts end up on an inpt unit, it is by accident (i.e. it was not recognized that their presentation was due to a neurodegenerative disease beforehand). There are very few neuropsych/neurobehavior inpt units. There are lots of geropsych units that take pts with behavioral and psychological symptoms of dementia. This also comes up in nursing home settings and in C-L psychiatry. And yes, we review imaging and often pick up things the neuroradiologists didn't comment on etc. In inpatient settings it's all about symptom management, very little about diagnosis. Usually these patients are not going to be able to going into a scanner or tolerate LP due to agitation etc. In the outpatient setting you get to think more diagnostically and may be ordering and reviewing different imaging (e.g. MRI, FDG-PET, amloid PET, DaTScan) and labs (e.g. Alzheimer's biomarkers, autoimmune encephalopathy panel, infectious, nutritional, metabolic etc), and possibly genetic tests (e.g. deterministic genes with neurogenetics consult, whole exome sequencing, chromosomal microarray).

Generally if neurology is consulting though they will be doing much of the workup and are either asking about whether there is a psychiatric etiology for the neurocognitive impairment (e.g. depression, functional cognitive disorder, ASD, psychotic illness, bipolar, personality disorder), because of comorbid psychiatric diagnoses (e.g. depression and dementia, or pt with SMI who is now developing cognitive decline), for psychopharmacological management of behavioral and psychological symptoms of dementia, or for complex ethical medicolegal issues or psychosocial complexity.

 

[splik]

I don't mind talking to people. I have some youth counseling background prior to medical school. But these kids were high functioning without ADHD, schizo, bipolar, and such.
EXAMPLES
(1) I had a pt in FM who was so tangential. I asked if she had trauma to her finger and she didn't stop talking about the dinner she had where she met her son-in-law and how great he was. Even with multiple redirection should couldn't just answer my questions appropriately... Left the room so exhausted ...
(2) A 30 year old female borderline girl came in for follow up of a recent pneumothorax hospital course. Soon found out she had 2 kids and 9 miscarriages. She also had plethora of health issues and her mood was so labile. It was tough connecting with her and sympathizing for her at a certain point.
Like I enjoy conversing with people, and I also do find psych pathologies fascinating. Sometimes, however, talking with psych patients really take a toll and I'm afraid that this is a SIGN for me to not go into it. Did you guys click with psych patients as a med student? Could you not see yourself doing anything else but psych? Did you not have a time where you felt the same way and just found the tangential speech a drag? What was about psych that drew you in while as a med student?

Psychiatrists are not endless wells of compassion. You should be able to connect with most patients but there is still going to be a good chunk where it might be hard. Patients may enrage you, frustrate you, frighten you, disgust you, despair you, and even bore you at times. I sometimes fall asleep if pts bore me. But that is a helpful countertransference reaction and can give you a clue about what might be going on. Some patients will be difficult to redirect but this is also a skill you will learn how to manage as a psychiatrist. In addition, the more you understand about why patients have the problems they do and get a window into their lives, it is easier to empathize with their plight. Additionally, there will be factors based on your own baggage that might lead you to react negatively or find it hard to connect with certain patients, but that is something you explore in supervision or your own therapy, which will allow you to be more effective. Having negative feelings towards patients does not make someone a bad doctor, nor does it mean they aren't suited to psychiatry. it makes them human.

 

[painballer27]

Regarding these $600k jobs...don't trust everything you read. There's some prison jobs and horrible locations that pay a bit more than $250k, but $400k is really stretching reality for the vast majority of salaried jobs. Of course, non-salaried jobs where you provide poor care and see way too many patients, the sky's the limit.

Okay, I see. Thanks for clarification. I know some people have argued in the past that it is possible to see a large volume of patients and still provide good care which is also an interested perspective. How easy is it to find these non-salaried types of jobs?

 

[adiradirim]

Day to day, pain management can be a nice mix of these 2 specialties by the way

 

[yanks26dmb]

Okay, I see. Thanks for clarification. I know some people have argued in the past that it is possible to see a large volume of patients and still provide good care which is also an interested perspective. How easy is it to find these non-salaried types of jobs?

It's not hard to make 400k. Around here (major metro), a big insurer is reimbursing 99214 + 90833 roughly $180. Do two of these an hour for 8 hours x 4 days a week x 47 weeks a year and you're making 540k. Subtract billing (~7%) and other overhead (another 5%) and you're still looking at 480k a year without any other business deductions.

Bring on a single NP (a quality one) and make another 50-70k a year off their work. Now you're well over half a mil a year working 4 days a week. And you don't have to provide poor care either.

You'll almost never get something like this in a salaried job however. The key is to work for yourself, which in psych is ridiculously easy.

 

[smalltownpsych]

Opinion from someone who has worked with inpatient psychiatry. If you are really good at the job, you will be happy, as simple as that. You don’t have to connect with patients other than to get the key info from them to determine an appropriate medication strategy. Case formulation, rational, thought processes, and extensive knowledge is what really separates the good from the bad. Coincidentally it is also what many members of the team on inpatient might be lacking. Another key is getting along with the other members of said team. A happy psychiatrist tolerates the fuzzy emotion based reasoning and despite some of that recognizes team members can have valuable insights or information.

 

[Ellomate]

It's not hard to make 400k. Around here (major metro), a big insurer is reimbursing 99214 + 90833 roughly $180. Do two of these an hour for 8 hours x 4 days a week x 47 weeks a year and you're making 540k. Subtract billing (~7%) and other overhead (another 5%) and you're still looking at 480k a year without any other business deductions.

Bring on a single NP (a quality one) and make another 50-70k a year off their work. Now you're well over half a mil a year working 4 days a week. And you don't have to provide poor care either.

You'll almost never get something like this in a salaried job however. The key is to work for yourself, which in psych is ridiculously easy.

Is this for inpatient or outpatient?
I have no exposure to outpatient so I'm just a little worried about my tolerance on doing 8 hour psychotherapy. or even 6 hour psychotherapy + 2 hour med management.

If inpatient, how do you even go about finding a job like that? It doesn't seem like it's locum. Wouldn;t hospitals just find someone to pay salary instead of what you mentioned above?

 

[Ellomate]

Day to day, pain management can be a nice mix of these 2 specialties by the way

I don't think I'd like to suboxone clinic or anything similar. I think to supplement income, i'll be interested in TMS/ECT or telemed. My PD does TMS so I shadowed her one day and it seems reasonable. Not too sure on the evidence on TMS tbh, but I think ECT may be the way if I want to see real change.

 

[Ellomate]

Opinion from someone who has worked with inpatient psychiatry. If you are really good at the job, you will be happy, as simple as that. You don’t have to connect with patients other than to get the key info from them to determine an appropriate medication strategy. Case formulation, rational, thought processes, and extensive knowledge is what really separates the good from the bad. Coincidentally it is also what many members of the team on inpatient might be lacking. Another key is getting along with the other members of said team. A happy psychiatrist tolerates the fuzzy emotion based reasoning and despite some of that recognizes team members can have valuable insights or information.

Yea for sure!
In my limited experience, the inpt psychiatrist finish seeing pt by 12pm. Then maybe 1 admission or max 2. Then around 3pm, they are just hanging out. For me, I wanna be go home rather than lounging around the hospital just waiting for some work. I'm pretty efficient so I think I'll be done in the early afternoon in the inpt setting. So i wanted to know if majority of the gigs out there allow for that or if they make the doc stay until 5pm.

 

[painballer27]

Is this for inpatient or outpatient?
I have no exposure to outpatient so I'm just a little worried about my tolerance on doing 8 hour psychotherapy. or even 6 hour psychotherapy + 2 hour med management.

If inpatient, how do you even go about finding a job like that? It doesn't seem like it's locum. Wouldn;t hospitals just find someone to pay salary instead of what you mentioned above?

I believe the above post is about opening your own outpatient private practice.

 

[adiradirim]

I don't think I'd like to suboxone clinic or anything similar. I think to supplement income, i'll be interested in TMS/ECT or telemed. My PD does TMS so I shadowed her one day and it seems reasonable. Not too sure on the evidence on TMS tbh, but I think ECT may be the way if I want to see real change.

Pain management is a separate specialty specifically to treat chronic pain conditions and sequelae using medications, injections, procedures, physical modalities, and behavioral changes. Suboxone clinics are very different and are to treat opioid addiction which may or may not be related to pain issues.

 

[hamstergang]

Around here (major metro), a big insurer is reimbursing 99214 + 90833 roughly $180. Do two of these an hour for 8 hours x 4 days a week x 47 weeks a year and you're making 540k. Subtract billing (~7%) and other overhead (another 5%) and you're still looking at 480k a year without any other business deductions.

How realistic do you think filling such a schedule consistently would be? Also, you're estimating 12% overhead only -- I feel I've seen more oven average in other threads but could be misremembering.

 

[Ellomate]

anothing thing I have a hard time wrapping my head is that almost everyone psychiatrists LOVES their job.
With selection bias, you can most certainley find people regretting their choice in any specialty - IM, FM, Surgery, Anesthesia, EM, etc...
However, it is very difficult to find psychiatrist who regrets their decision or does not like their job. Trust me I've searched with the intention of finding negative comments.

I've read multiple forms and reached out to many practicing psychiatrist and think I only saw one person who regretted it. That's like 1/100.
Why is this so?
Was psych a match made in heaven in medical school?
I also see several people going to psych bc they hated med school and just wanted something they hated the least. But in the end, they love their jobs.
What is it about psych that generates such job satisfaction.
Are my worries on emotional burden and burn out a little out of proportion?

 

[Jules A]

Yea for sure!
In my limited experience, the inpt psychiatrist finish seeing pt by 12pm. Then maybe 1 admission or max 2. Then around 3pm, they are just hanging out. For me, I wanna be go home rather than lounging around the hospital just waiting for some work. I'm pretty efficient so I think I'll be done in the early afternoon in the inpt setting. So i wanted to know if majority of the gigs out there allow for that or if they make the doc stay until 5pm.

I have worked on several inpatient units and 2pm is a more realistic expectation particularly in consideration of morning team meeting. At some hospitals the psychiatrists round then leave and other places if they had to cover CL or ED that is where they were for the rest of the afternoon. My current unit prefers new admits who are on the floor by 3pm to be seen for an eval that day.

 

[painballer27]

It's not hard to make 400k. Around here (major metro), a big insurer is reimbursing 99214 + 90833 roughly $180. Do two of these an hour for 8 hours x 4 days a week x 47 weeks a year and you're making 540k. Subtract billing (~7%) and other overhead (another 5%) and you're still looking at 480k a year without any other business deductions.

Bring on a single NP (a quality one) and make another 50-70k a year off their work. Now you're well over half a mil a year working 4 days a week. And you don't have to provide poor care either.

You'll almost never get something like this in a salaried job however. The key is to work for yourself, which in psych is ridiculously easy.

If the demand is there, why not bring on 5 NPs, make an additional 250-300 off of them, cut back to three days yourself and enjoy?

 

[painballer27]

I have worked on several inpatient units and 2pm is a more realistic expectation particularly in consideration of morning team meeting. At some hospitals the psychiatrists round then leave and other places if they had to cover CL or ED that is where they were for the rest of the afternoon. My current unit prefers new admits who are on the floor by 3pm to be seen for an eval that day.

How many patients are these 2pm leaving docs seeing a day and how much are they making?

 

[Jules A]

How many patients are these 2pm leaving docs seeing a day and how much are they making?

Generally 8-10 patients, $350k-ish most require some call and a couple of hospitals still make attendings pick up a weekend q month or q 6 weeks.

 

[painballer27]

Generally 8-10 patients, $350k-ish most require some call and a couple of hospitals still make attendings pick up a weekend q month or q 6 weeks.

Okay I feel like that’s pretty good for 8-10. Shouldn’t take until 2 to see that many

 

[psyspy]

It's not hard to make 400k. Around here (major metro), a big insurer is reimbursing 99214 + 90833 roughly $180. Do two of these an hour for 8 hours x 4 days a week x 47 weeks a year and you're making 540k. Subtract billing (~7%) and other overhead (another 5%) and you're still looking at 480k a year without any other business deductions.

Bring on a single NP (a quality one) and make another 50-70k a year off their work. Now you're well over half a mil a year working 4 days a week. And you don't have to provide poor care either.

You'll almost never get something like this in a salaried job however. The key is to work for yourself, which in psych is ridiculously easy.

I presume nothing of this sort would really be possible to command in an inpatient role?

 

[yanks26dmb]

How realistic do you think filling such a schedule consistently would be? Also, you're estimating 12% overhead only -- I feel I've seen more oven average in other threads but could be misremembering.

Around here people are filling within 3 months. Percent overhead is relative. Some costs are fixed regardless of your revenue. At that revenue I feel like 5% should cover it... Particularly with a mostly tele practice

 

[painballer27]

I presume nothing of this sort would really be possible to command in an inpatient role?

Again I’m a med student still so don’t know a lot but from my understanding if you had a 1099 inpatient job with a high patient load you could probably hire a herd of NPs to help you round and collect off them. One of my objectives on this thread is to figure out how common these setups are.

 

[psych_0]

Generally 8-10 patients, $350k-ish most require some call and a couple of hospitals still make attendings pick up a weekend q month or q 6 weeks.

If I'm seeing 8 patients and leaving at 2pm, it's because I had a long lunch and then a meeting at 1pm. I see 12-15/day and leave around 1pm (which is after a leisurely lunch). Granted, I get in around 7am but still. If I had to stay in the hospital until 2pm every day I would find a new job, and it would not be difficult. Pretending that someone does a "better" job than me because they stay in the hospital later in the day than I do is just that, pretend. My colleagues at my current job as well as my inpatient friends from residency (n = 7) all have a similar schedule.

Working in-house call one weekend per month is standard. I have seen zero inpatient jobs (n = 6) where weekend call is not required. If you find one that is offering a good offer (salary + wRVU bonus) with no weekend call, jump on it. As far as the weekdays, this is where it varies. My job has an NP cover 365 days a year overnight so our call is only via phone call until the evening, one weekday per week on average. I have friends from residency who cover one full week 24/7 out of each month on call via phone. This sounds miserable.

 

[Jules A]

If I'm seeing 8 patients and leaving at 2pm, it's because I had a long lunch and then a meeting at 1pm. I see 12-15/day and leave around 1pm (which is after a leisurely lunch). Granted, I get in around 7am but still. If I had to leave the hospital at 2pm every day I would find a new job, and it would not be difficult. Pretending that someone does a "better" job than me because they stay in the hospital later in the day than I do is just that, pretend. My colleagues at my current job as well as my inpatient friends from residency (n = 7) all have a similar schedule.

Working in-house call one weekend per month is standard. I have seen zero inpatient jobs (n = 6) where weekend call is not required. If you find one that is offering a good offer (salary + wRVU bonus) with no weekend call, jump on it. As far as the weekdays, this is where it varies. My job has an NP cover 365 days a year overnight so our call is only via phone call until the evening, one weekday per week on average. I have friends from residency who cover one full week 24/7 out of each month on call via phone. This sounds miserable.

I’ve never seen anyone start at 7am generally between 8a-9a depending on what time the dreaded treatment team happens. Bummer about your weekends.

 

[smalltownpsych]

I’ve never seen anyone start at 7am generally between 8a-9a depending on what time the dreaded treatment team happens. Bummer about your weekends.

“Dreaded treatment team“ 🤣
Maybe that would be a good test to see if you have what it takes to be in the field. If you can’t tolerate people saying ignorant, ill-informed, repetitive things every single morning at 8:00 am then inpatient could be a problem. These meetings can be really toxic if the setup is for the psychiatrist to make every decision and the other team members are all just lobbying/angling for approval or if plans in treatment team are seen as the final say. Groupthink is a real and very negative dynamic so there needs to be a counter to that. I always empowered my people to bring their second thoughts or any new information to me if they arose after treatment team.
I actually enjoy studying pathological groups and knowing when and how to intervene to improve unhealthy group dynamics so that helps me personally deal with treatment team.

 

[J ROD]

OP, you sound like Anes. That is all.

 

[painballer27]

How common is it for psychiatrists to work an inpatient job in the morning while building an outpatient private practice at the same time?

 

[Trismegistus4]

If I had to leave the hospital at 2pm every day I would find a new job

Did you mean if you had to stay at the hospital until 2pm every day you would find a new job?

 

[Candidate2017]

I don't mind talking to people. I have some youth counseling background prior to medical school. But these kids were high functioning without ADHD, schizo, bipolar, and such.
EXAMPLES
(1) I had a pt in FM who was so tangential. I asked if she had trauma to her finger and she didn't stop talking about the dinner she had where she met her son-in-law and how great he was. Even with multiple redirection should couldn't just answer my questions appropriately... Left the room so exhausted ...
(2) A 30 year old female borderline girl came in for follow up of a recent pneumothorax hospital course. Soon found out she had 2 kids and 9 miscarriages. She also had plethora of health issues and her mood was so labile. It was tough connecting with her and sympathizing for her at a certain point.
Like I enjoy conversing with people, and I also do find psych pathologies fascinating. Sometimes, however, talking with psych patients really take a toll and I'm afraid that this is a SIGN for me to not go into it.

These are run of the mill "average" medical patients. If you are exhausted interacting with these medical patients, it will be hell for you to deal with psychiatric patients, whether inpatient or outpatient.

Did you actually interact with any psychiatric inpatients on your rotation? Manic, psychotic, substance, borderline, antisocial and/or homicidal patients?

30 seconds of polite chit chat, check that Mallampati score, bye, see you in the OR, tube in the airway, ignore the surgeon's jokes, crossword puzzles, check stocks, rinse and repeat seems like your fit.

 

[comp1]

I have never heard of a 1099 psychiatrist bringing in their own NPs to round on patients. I guess it is technically possible, I just haven't seen it. Much more common for a salaried psychiatrist to oversee also hospital employed NPs. The outpatient estimate of income above with 99214's seems optimistic, but I don't do outpatient. It's definitely optimistic for inpatient. Definitely second the idea that if you are dreading treatment team...don't do inpatient psych or at least don't do it anywhere you dread the treatment team. Treatment team should be the highlight of the day.

 

[Ellomate]

I'm not sure what a 1099 is, but sounds like a contractor type of work?
Is it possible to be eligible for PSLF under 1099?

 

[nexus73]

I'm not sure what a 1099 is, but sounds like a contractor type of work?
Is it possible to be eligible for PSLF under 1099?

No

 

[comp1]

A 1099 is what a company uses to report to the IRS what they paid you as a contractor. It's like a W-2 for salaried employees, but with a 1099 you have to estimate all of the taxes on it and pay them yourself quarterly (including double some of them relative to a W-2).

 

[michaelrack]

I have never heard of a 1099 psychiatrist bringing in their own NPs to round on patients. I guess it is technically possible, I just haven't seen it. Much more common for a salaried psychiatrist to oversee also hospital employed NPs. The outpatient estimate of income above with 99214's seems optimistic, but I don't do outpatient. It's definitely optimistic for inpatient. Definitely second the idea that if you are dreading treatment team...don't do inpatient psych or at least don't do it anywhere you dread the treatment team. Treatment team should be the highlight of the day.

I see it done all the time

 

[psych_0]

Did you mean if you had to stay at the hospital until 2pm every day you would find a new job?

Correct lol. I edited it now.

 

[tr]

anothing thing I have a hard time wrapping my head is that almost everyone psychiatrists LOVES their job.
With selection bias, you can most certainley find people regretting their choice in any specialty - IM, FM, Surgery, Anesthesia, EM, etc...
However, it is very difficult to find psychiatrist who regrets their decision or does not like their job. Trust me I've searched with the intention of finding negative comments.

I've read multiple forms and reached out to many practicing psychiatrist and think I only saw one person who regretted it. That's like 1/100.
Why is this so?
Was psych a match made in heaven in medical school?
I also see several people going to psych bc they hated med school and just wanted something they hated the least. But in the end, they love their jobs.
What is it about psych that generates such job satisfaction.
Are my worries on emotional burden and burn out a little out of proportion?

Psych is just very controllable, more so than almost any other specialty.
Psychiatrists are generally in high demand so have market power to set their terms of employment.

For people who like inpatient, hospital setting (C/L), or procedures (neurostim: ECT, TMS, tDCS, etc), those are all options.

For people who don't, there's always the option to opt out of the system and strike out as an independent operator for cash with almost no overhead (because no procedures or equipment), no insurance headache, and total control over your hours and schedule. I don't think there's another specialty that has that escape hatch.

Psych doesn't stand out as a moneymaker but I think that's because most people in the field choose to work fewer hours than those in other specialties - also something that isn't an option in many procedural specialties. The hours-to-dollars ratio is actually quite favorable for psych compared to other fields.

If you hate talking to people and your other option was anesthesia, I'd suggest you consider an ECT/TMS specialization. Just place the electrodes/magnet, flip on the switch, and count your money.

 

[Ellomate]

Psych is just very controllable, more so than almost any other specialty.
Psychiatrists are generally in high demand so have market power to set their terms of employment.

For people who like inpatient, hospital setting (C/L), or procedures (neurostim: ECT, TMS, tDCS, etc), those are all options.

For people who don't, there's always the option to opt out of the system and strike out as an independent operator for cash with almost no overhead (because no procedures or equipment), no insurance headache, and total control over your hours and schedule. I don't think there's another specialty that has that escape hatch.

Psych doesn't stand out as a moneymaker but I think that's because most people in the field choose to work fewer hours than those in other specialties - also something that isn't an option in many procedural specialties. The hours-to-dollars ratio is actually quite favorable for psych compared to other fields.

If you hate talking to people and your other option was anesthesia, I'd suggest you consider an ECT/TMS specialization. Just place the electrodes/magnet, flip on the switch, and count your money.

I've seen TMS before and I'm very skeptical on the efficacy of the treatment.. But I guess if someone has intractable depression and TMS helps like 10% I guess that's better than nothing.

Is interventional psychiatry becoming a thing? I know there's a lot of research being pumped in the psych world and was wondering if there is a push for such a niche? Perhaps a new fellowship? Thoughts on this anyone?