Is psychiatry worth it economically/job security speaking?

[bGMx]

Title asks the question. I'm an M1 at a good MD school and have been orienting my life around psych for the last 5 years (clinical work, research, authorship, interests etc). I do wonder if there is some sort of problem with the economics however, given all the recent threads in SDN about NPs... it seems as though its hard to really quantify the difference between an average psychiatrist and an average NP. I aspire to practice at the top of my license, but I'm still curious about what you all think about the future of the profession. Of course we don't have a crystal ball so I'm hoping for speculative opinions for me to consider and make informed decisions on.

So if you were an M1, and you've oriented your career around psychiatry, what advice would you give to yourself?
To pursue or not to pursue!

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[90833]

If you worry about encroachment, your best options are pathology, radiology, surgery, and radiation oncology.

Psychiatry has already been mostly pushed out of therapy by psychologists and LCSWs.

 

[Merovinge]

I think it's a mistake to choose your specialty around the concern for NPs. They are doing independent surgery as of 2021, so I'm not sure what fields are safe from encroachment (I've seen them in primary care, psych, every medical and peds specialty, nearly every surgery specialty, obviously gas, rads, pathology). Either the market will accept that health care can be provided by people with minimal training and continue to push towards health care "providers" being a slightly fancier version of an auto mechanic with dramatically less training then we require for people who take care of our cats, or it won't. The only way to protect yourself from the former completely is to drop out of medical school now and pursue data science. I, for one, would feel just fine taking the risk to pursue one of the best vocations throughout the recorded history record of humanity.

 

[vistaril]

Title asks the question. I'm an M1 at a good MD school and have been orienting my life around psych for the last 5 years (clinical work, research, authorship, interests etc). I do wonder if there is some sort of problem with the economics however, given all the recent threads in SDN about NPs... it seems as though its hard to really quantify the difference between an average psychiatrist and an average NP.

of course....because the day to day/hour to hour differences in function are very little.

At my shop they are basically identical in inpatient settings....except a psych has to 'sign off' and lay eyes on the patient. In the outpt setting, the roles and duties are 100% identical. Quality of care? Perhaps a little better from the psych np side of things....but that probably has more to do with the individuals than anything else and how many they see per day. I don't think there are any significant differences in quality of care one way or the other between psychs and psych nps if you adjust for this. True, psych nps are probably providing a little better care overall now than psychs, but take away the differences and make the pt loads equivalent and those gaps would dissapear and the psychs would be just as good. You'd also have to take away cultural/language barriers when applicable.....

If you are looking for a role that distinguishes yourself from nps, obviously you don't want to do psych. Anesthesia and EM would be two others to avoid. But there are plenty of good options- surgery is of course safe, as are most of the procedure based medicine fellowships. NPs are not going to be doing stents anytime soon for example.

So if you are a med student who could see yourself doing something else, then definately pick something else. Most psychs, however, especially those at american schools(lots of IMGS match it just because it's an easier match relatively) really couldn't see or picture or feeling comfortable doing something else. I'm definately in that category. A lot of them will say things like "oh yeah it was between psych and doing brain surgery, but in the end my fascination with starting someone on 20mg of celexa beat out separating conjoined twins".....there is wrong with one admitting that psych was always the choice(after rotations started at least); at least it's honest.

 

[vistaril]

I think it's a mistake to choose your specialty around the concern for NPs. They are doing independent surgery as of 2021

oh gosh I knew this post was coming......

surgery is safe from nps. To argue anything else is absurd.

 

[nexus73]

of course....because the day to day/hour to hour differences in function are very little.

At my shop they are basically identical in inpatient settings....except a psych has to 'sign off' and lay eyes on the patient. In the outpt setting, the roles and duties are 100% identical. Quality of care? Perhaps a little better from the psych np side of things....but that probably has more to do with the individuals than anything else and how many they see per day. I don't think there are any significant differences in quality of care one way or the other between psychs and psych nps if you adjust for this. True, psych nps are probably providing a little better care overall now than psychs, but take away the differences and make the pt loads equivalent and those gaps would dissapear and the psychs would be just as good. You'd also have to take away cultural/language barriers when applicable.....

If you are looking for a role that distinguishes yourself from nps, obviously you don't want to do psych. Anesthesia and EM would be two others to avoid. But there are plenty of good options- surgery is of course safe, as are most of the procedure based medicine fellowships. NPs are not going to be doing stents anytime soon for example.

So if you are a med student who could see yourself doing something else, then definately pick something else. Most psychs, however, especially those at american schools(lots of IMGS match it just because it's an easier match relatively) really couldn't see or picture or feeling comfortable doing something else. I'm definately in that category. A lot of them will say things like "oh yeah it was between psych and doing brain surgery, but in the end my fascination with starting someone on 20mg of celexa beat out separating conjoined twins".....there is wrong with one admitting that psych was always the choice(after rotations started at least); at least it's honest.

what do you mean by the highlighted. The nps around me can't seem to stop diagnosing borderline patients as bipolar, or cycling through antidepressants every month without adequate trials and have everyone on Viibryd within 3 months of starting med trials.

 

[Merovinge]

oh gosh I knew this post was coming......

surgery is safe from nps. To argue anything else is absurd.

I'll get right on telling my wife, a surgeon, who has literally watched NPs perform independent surgery running an independent OR (while applying for a job), that she is, in fact, absurd. Wish me luck!

 

[psychacad]

There's really no evidence that NPs have hit the psych job market, regardless of what the SDN "intelligentia" think. Right now, you can get a good paying job anywhere with a ton of flexibility, that is if you don't opt to open your practice where the opportunities are even better. The situation is arguably better than it was a decade or even 5 years ago. Mental health is in more demand than ever and the demand is likely to increase.

I think you're gravely mistaken if you want to base your career on the "educated" speculations of a handful of SDNers. I start worrying when I see data.

For what it's worth, n=1, competent NPs are hard to come by. They are either inefficient, incompetent or more often both.

 

[SmallBird]

If you worry about encroachment, your best options are pathology, radiology, surgery, and radiation oncology.

Psychiatry has already been mostly pushed out of therapy by psychologists and LCSWs.

Pathology has other encroachment problems like machines that just genotype tissue and dramatically reduce the need for people to look under microscopes. I've heard they have a really bad job market.

 

[nexus73]

realistically, get trained in whatever specialty you want, and get a health care MBA during the latter part of your residency, then get out and you won't have to do any work, just be a pain in the butt for the doctors who are doing the actual work.

 

[SmallBird]

Title asks the question. I'm an M1 at a good MD school and have been orienting my life around psych for the last 5 years (clinical work, research, authorship, interests etc). I do wonder if there is some sort of problem with the economics however, given all the recent threads in SDN about NPs... it seems as though its hard to really quantify the difference between an average psychiatrist and an average NP. I aspire to practice at the top of my license, but I'm still curious about what you all think about the future of the profession. Of course we don't have a crystal ball so I'm hoping for speculative opinions for me to consider and make informed decisions on.

So if you were an M1, and you've oriented your career around psychiatry, what advice would you give to yourself?
To pursue or not to pursue!

I have been an attending for 4 years, and couldn't be happier with how things have worked out. I worked very hard to make sure that I was going to be able to do a good job in individual care, teaching, and leadership, which has helped me access roles that offer good work life balance, a sense of satisfaction and meaning, and a lot of money. I have worked with nurse practitioners every step of the way and they have done a good job seeing their patients but our roles have been very different. The systems I have worked in have always placed a very high degree of importance on good outcomes, low re-admission rates, press-ganey scores, low restraint rates, and low rates of insurance denial. So I made sure I knew how to get units to function in a way that achieved those goals, which incidentally aligned with my own interests in providing good care and teaching. This also helped the system make a ton of additional revenue in facility billing, and they increased my salary in response. Quality does matter to many institutions - if you pick the right medications and can get a patient stable more quickly and discharge them before they run out of covered days, that is good for the system. If you have skills in diverse psychotherapies and can leverage this to build alliance and get patients to engage well in treatment, you will have fewer restraints, lower staff turnover, and significantly reduced cost. Blue Cross offered our hospital 3 x what they were offering a neighboring CMHC for our PHP because we showed with data that we got significantly better outcomes. I am not going to post my salary but I am about 7-8 years from being able to retire and I work 4 weeks on, 2 weeks off, in a very desirable location that I literally picked in the middle of COVID by making a list of locations and ranking them according to what I and my spouse cared about. I don't have an MBA and didn't do another degree but if you are willing to work hard to have some concrete way to add value you can do really well. I think if you would like to just see your patients and go home in a manner identical to what an NP is doing there is greater risk that you will be under salary pressure in some settings. I can't predict the future but this is my recent experience and when I started residency people were also posting on this forum saying NPs would destroy everything.

 

[SourceOfDenial]

I mean, I wouldn’t take any career advice from this forum or SDN in general. But, since you’ve asked...

Pick what you like. The bigger detriment to psychiatry is just bad psychiatrists.

 

[Monocles]

If I were a pre-med I would have done the smart thing and ran away from medicine altogether.

However as an M1, even knowing what I know today I would 1000x still choose psychiatry b/c I hate every other specialty more lol. At least I enjoy the psych work piece.

Personally I think the NP encroachment issue is far overblown - however I may be insulated by the fact that I work in Boston and protected in the "bubble" from the economic realities. My take as an amateur economist is this - having done residency and fellowship in the "most psychiatrist per capita" city in the world, you can crank out and flood the country with thousands of NPs and midlevels each year and it 1) wouldn't make a dent in the mental health crisis and 2) would not affect your bottom line as an MD/DO physician. In some ways by having gone through additional med training, you differentiate yourself more amongst the sea of midlevel providers (some of which are excellent, but a greater amount may be terrible).

Out of curiosity I looked up the private practice rates and see dozens and dozens of $250-300 per hour NPs and SWs and psychologist etc. Talking to MD friends w/ pps charging $800+, they have an endless waitlist b/c the people with true means out there will pay top bucks to see the physicians over the midlevels.

 

[Sushirolls]

I'm in a saturated market next to an ARNP mill. And it has real impacts. Look to the EM forums.

The market impacts of midlevel saturation can be real, look to the case study of the closed environment of EM. The multiple areas of Psychiatry with IP/CL/OP/PHP/IOP/Residential etc will weather the storm longer, but people need to open their eyes and see the storm is coming and there will be limited environments that will preference the quality of a Physician.

Dynamics of insurance companies, one only needs to look to UHC and its behavior as a for profit, publicly traded, dividend yielding insurance company. They are the trend setters of the Scat that is coming.

This coal mine canary has a cough.

 

[rjs2131]

of course....because the day to day/hour to hour differences in function are very little.

At my shop they are basically identical in inpatient settings....except a psych has to 'sign off' and lay eyes on the patient. In the outpt setting, the roles and duties are 100% identical. Quality of care? Perhaps a little better from the psych np side of things....but that probably has more to do with the individuals than anything else and how many they see per day. I don't think there are any significant differences in quality of care one way or the other between psychs and psych nps if you adjust for this. True, psych nps are probably providing a little better care overall now than psychs, but take away the differences and make the pt loads equivalent and those gaps would dissapear and the psychs would be just as good. You'd also have to take away cultural/language barriers when applicable.....

If you are looking for a role that distinguishes yourself from nps, obviously you don't want to do psych. Anesthesia and EM would be two others to avoid. But there are plenty of good options- surgery is of course safe, as are most of the procedure based medicine fellowships. NPs are not going to be doing stents anytime soon for example.

So if you are a med student who could see yourself doing something else, then definately pick something else. Most psychs, however, especially those at american schools(lots of IMGS match it just because it's an easier match relatively) really couldn't see or picture or feeling comfortable doing something else. I'm definately in that category. A lot of them will say things like "oh yeah it was between psych and doing brain surgery, but in the end my fascination with starting someone on 20mg of celexa beat out separating conjoined twins".....there is wrong with one admitting that psych was always the choice(after rotations started at least); at least it's honest.

I’m confused by this post...are you saying that psych NPs provide better care than psychiatrists?

Also...psych isn’t an easy match anymore and has actually gotten pretty competitive. Recent numbers support this and Ive heard of at least a few competitive applicants who didn’t match this year.

To answer OP - pursue what you actually enjoy and can see yourself doing for several years. None of us can predict the job market but people will always need mental health care and I think the need/demand will only continue to go up. The average psychiatrist is making more now than they did 10-20 years ago.

 

[Stagg737]

I aspire to practice at the top of my license, but I'm still curious about what you all think about the future of the profession.

Then you should aspire for neurosurgery or forget the phrase "top of my license" as it's something typically said by admins and mid-levels looking for more independent practice. Mid-levels seeking FPA is an issue, though imo not as much in psych as in other areas of medicine.

To add another N=1, a fairly significant amount of my new evals come to our program after seeing NPs who just threw meds at them or made things worse. Go into a field you enjoy and get really good at it or find a niche that other's can't or won't fill. That's the best job security you'll find in any field.

True, psych nps are probably providing a little better care overall now than psychs, but take away the differences and make the pt loads equivalent and those gaps would dissapear and the psychs would be just as good.

Lol, what? Where you practice sounds terrifying...

NPs are not going to be doing stents anytime soon for example.

NPs can already perform angiograms and PCIs in some places and perform invasive procedures unsupervised in some ICUs. Areas like neurosurg or transplant are surely safe, but with a hard enough push NPs could claim more general/less complex procedures are within their scope.

 

[Bartelby]

I am about four years out of training and have work-life balance that many physicians would envy (over 300k for just over 40 hours worked per week, and not at any kind of grind house pace or volume). There was plenty of doom and gloom when I was choosing my specialty but so far everything for me has worked out great. No one can guarantee what the future holds but I am not very worried.

 

[dl2dp2]

This particular arrangement I'm in has paid dividends beyond my wildest imagination. However, it may be difficult to duplicate.

 

[finalpsychyear]

NP encroachment is real. Go surgical subspecialist/rads/anesthesia with fellowship to minimize this. Just a matter of time indep license opens up in a bunch more states.

 

[vistaril]

I'll get right on telling my wife, a surgeon, who has literally watched NPs perform independent surgery running an independent OR (while applying for a job), that she is, in fact, absurd. Wish me luck!

please send me the link to a practice *anywhere* that advertises nps as doing surgeries without surgeon.....until then, I'm pretty confident
surgery is safe.

I'll wait....

 

[vistaril]

This particular arrangement I'm in has paid dividends beyond my wildest imagination. However, it may be difficult to duplicate.

you are very non-descriptive bordering on evasive on what exactly you do, the setting you work in, your day to day, etc....since some of us are curious, could you elaborate some?

 

[vistaril]

Then you should aspire for neurosurgery or forget the phrase "top of my license" as it's something typically said by admins and mid-levels looking for more independent practice. Mid-levels seeking FPA is an issue, though imo not as much in psych as in other areas of medicine.

To add another N=1, a fairly significant amount of my new evals come to our program after seeing NPs who just threw meds at them or made things worse. Go into a field you enjoy and get really good at it or find a niche that other's can't or won't fill. That's the best job security you'll find in any field.



Lol, what? Where you practice sounds terrifying...



NPs can already perform angiograms and PCIs in some places and perform invasive procedures unsupervised in some ICUs. Areas like neurosurg or transplant are surely safe, but with a hard enough push NPs could claim more general/less complex procedures are within their scope.

lol....same as I said to the other guy- show me these practices where the nps are doing unsupervised PCIs....

 

[vistaril]

I’m confused by this post...are you saying that psych NPs provide better care than psychiatrists?

Also...psych isn’t an easy match anymore and has actually gotten pretty competitive. Recent numbers support this

No, they don't. Still amongst the highest percentages of IMGs. If anything psychiatry is even less competitive in some respects.

As to the first part, sure...in many cases. But those cases usually involve a situation where the psych is just seeing so much more volume than the np(and supervising other nps) that they can't keep the patients straight. Or cases where the psych and pts have a language or cultural barrier and that hinders things. Taking those two things out of the equation, I think quality differences in most all psych settings between psychs and psych nps are negligible.

 

[dl2dp2]

you are very non-descriptive bordering on evasive on what exactly you do, the setting you work in, your day to day, etc....since some of us are curious, could you elaborate some?

I work in South Florida and in full-time cash outpatient pp. There's nothing mysterious or interesting. Very typical cash practice I'd say. Just happen to make a lot and work very little. Most of my free time is spent on hobbies. Not interested in saying more as you'd be able to guess who I am based on my old posts.

 

[robellis]

I work in South Florida and in full-time cash outpatient pp. There's nothing mysterious or interesting. Very typical cash practice I'd say. Just happen to make a lot and work very little. Most of my free time is spent on hobbies.

How much do you make and how many hours per week?

 

[dl2dp2]

How much do you make and how many hours per week?

Let's just say my schedule C top line grossed substantially more than 500k last year and work less than 20 hours a week--was just doing taxes, but bottom line is very low because of substantial reinvestment--so it's very hard to say what exactly is it that "I make". But my investments actually went up more than 500k last year, and this is not counting real estate. Weird times.

 

[robellis]

Let's just say my schedule C grossed substantially more than 500k last year and work less than 20 hours a week--was just doing taxes. But my investments actually went up more than 500k last year, and this is not counting real estate,. Weird times.

700k for 20 hours of work? Wow lol

 

[dl2dp2]

700k for 20 hours of work? Wow lol

People I know charge more. I'm maybe upper quartile, upper tenth. A handful of people break 1M doing pure cash working 25 hours a week around here. The amount of private money in America shouldn't be underestimated. I think it happens more often than you think, and it's not even new info. Just look at the MGMA curve. About 3% of psychiatrists make more than 700k.

OTOH, I have essentially zero "job security", as I don't really have a job. However, this doesn't matter since my investments can cover my living expenses. Live frugally and save and invest allows you to take on more risk which increases earning potential.

I also don't really compete with NPs. Nobody I see would be interested ever to see an NP.

 

[calvnandhobbs68]

No, they don't. Still amongst the highest percentages of IMGs. If anything psychiatry is even less competitive in some respects.

As to the first part, sure...in many cases. But those cases usually involve a situation where the psych is just seeing so much more volume than the np(and supervising other nps) that they can't keep the patients straight. Or cases where the psych and pts have a language or cultural barrier and that hinders things. Taking those two things out of the equation, I think quality differences in most all psych settings between psychs and psych nps are negligible.

You keep mentioning language/cultural barriers over and over which again makes me think that you have a weird view of the field right now. Yeah, there's a decent amount of IMGs in psych but the majority of psych residents/attendings are NOT IMGs. So the "cultural/language" barrier stuff you mention, while it exists, doesn't really play as much of a factor in the field as a whole as you're making it seem.

Additionally, if an NP is better than you at your job, then you deserve to be replaced.

 

[thepoopologist]

Title asks the question. I'm an M1 at a good MD school and have been orienting my life around psych for the last 5 years (clinical work, research, authorship, interests etc). I do wonder if there is some sort of problem with the economics however, given all the recent threads in SDN about NPs... it seems as though its hard to really quantify the difference between an average psychiatrist and an average NP. I aspire to practice at the top of my license, but I'm still curious about what you all think about the future of the profession. Of course we don't have a crystal ball so I'm hoping for speculative opinions for me to consider and make informed decisions on.

So if you were an M1, and you've oriented your career around psychiatry, what advice would you give to yourself?
To pursue or not to pursue!

You have to do what you're ultimately interested in and can become decent/good or even excellent at. As an M1, I'd keep my options open depending on your grades, step scores, rotations and how well you get along with everyone. Obviously the job market for a specialty you've narrowed down will be a factor as well, you don't want to finish residency without a job, however it might do you well to not care about that till you're past step 1/closer to graduation and have a more complete academic record.

In my corner of the world everything is fine. I personally work 4/10s. I officially have a census of 25 however only need to see them 1/month or more regularly if they have pressing issues. This works out to about 3 pts a day. This is a full time job.

There are maybe 3-4 NPs at my facility, one with a DNP. I don't supervise any of them. They are given the easiest patients and ask questions like how to dose Trazodone and Zoloft and are paid slightly over 100k a year. They are nearly brain dead and had they not taken out loans to get an NP they'd be a day laborer or prostitute. I have come across NPs in other facilities who are quite good at their jobs, psychiatrists who are very careless and/or unknowledgeable, and vice versa. I've never gotten the sense that I'm in direct competition with an NP over any job however I can say that there exist clinician administrators who ultimately look for who is good and who can fit the needs of the facility. There are also administrators who don't care as long as you prescribe. I haven't seen any significant drops in salary or job flexibility so far but I'm not a fortune teller. Anyways you're talking about 8 years from now. 8 years ago when I was at the tailend of M4 the big specialties were Radiology, EM, Anesthesiology, Derm. Psych was considered an ok specialty for wayward souls back then.

In conclusion, $GME, $AMC, diamond hands, apes strong, etc

 

[AD04]

I work in South Florida and in full-time cash outpatient pp. There's nothing mysterious or interesting. Very typical cash practice I'd say. Just happen to make a lot and work very little. Most of my free time is spent on hobbies. Not interested in saying more as you'd be able to guess who I am based on my old posts.

I wish I could have known earlier. I would have liked to spend time on your boat before I left the state.

700k for 20 hours of work? Wow lol

You might want to study what a schedule C looks like.

 

[rjs2131]

No, they don't. Still amongst the highest percentages of IMGs. If anything psychiatry is even less competitive in some respects.

As to the first part, sure...in many cases. But those cases usually involve a situation where the psych is just seeing so much more volume than the np(and supervising other nps) that they can't keep the patients straight. Or cases where the psych and pts have a language or cultural barrier and that hinders things. Taking those two things out of the equation, I think quality differences in most all psych settings between psychs and psych nps are negligible.

Percentage of IMG's continues to go down each year from what I've seen...but I don't think this is particularly relevant anyway. Maybe you're speaking more to experience in inpatient settings, but I think the difference between an average psychiatrist and an average NP in the outpatient world is pretty substantial.

It also sounds like you're describing...bad psychiatrists? If you're seeing so many patients you can't keep them straight AND supervising NP's, you're probably just in it for the $$$ and could care less about quality of care. At this point sure, probably doesn't matter who is seeing the patients. I don't think this describes the average psychiatrist though I could be wrong (hope not).

 

[vistaril]

People I know charge more. I'm maybe upper quartile, upper tenth. A handful of people break 1M doing pure cash working 25 hours a week around here. The amount of private money in America shouldn't be underestimated. I think it happens more often than you think, and it's not even new info. Just look at the MGMA curve. About 3% of psychiatrists make more than 700k.

OTOH, I have essentially zero "job security", as I don't really have a job. However, this doesn't matter since my investments can cover my living expenses. Live frugally and save and invest allows you to take on more risk which increases earning potential.

I also don't really compete with NPs. Nobody I see would be interested ever to see an NP.

I know a lot of psychs who make more than 700k, but around here all do it with insurance based volume, nps, and having contracts that others do the work(although a single psych could get over 700k if they did high volume and had an np or two who was grinding)

The model you do is only available in certain places. A very small part of the country. South Florida is an area where there is obviously large pockets of very wealthy retirees. Same for some other places. But thats not the reality for most of the country.....that's why of that top 3% I would bet that the clear majority of them are doing it through grinding and volume than this 800 dollar an hour cash pay stuff....

Even if I had the skills or confidence to get 800 dollars an hour in cash pay settings(I don't), I've never lived in a place where that market is available. The best cash pay people were charging like 300-350 an hour and in the end after expenses and taking much reduced clinical volume into account were making less than us grinders(but probably had more job satisfaction)

 

[vistaril]

You keep mentioning language/cultural barriers over and over which again makes me think that you have a weird view of the field right now. Yeah, there's a decent amount of IMGs in psych but the majority of psych residents/attendings are NOT IMGs. So the "cultural/language" barrier stuff you mention, while it exists, doesn't really play as much of a factor in the field as a whole as you're making it seem.

Additionally, if an NP is better than you at your job, then you deserve to be replaced.

the IMG % in psychiatry is what it is....it's amongst the highest of all fields and holding pretty steady. DOs are way up there too....

you guys can actually look this stuff up you know

 

[vistaril]

Percentage of IMG's continues to go down each year from what I've seen...but I don't think this is particularly relevant anyway. Maybe you're speaking more to experience in inpatient settings, but I think the difference between an average psychiatrist and an average NP in the outpatient world is pretty substantial.

you would think wrong. Most patients don't care....some don't even know. They just want to get their meds lol.....

 

[psychacad]

I work in South Florida and in full-time cash outpatient pp. There's nothing mysterious or interesting. Very typical cash practice I'd say. Just happen to make a lot and work very little. Most of my free time is spent on hobbies. Not interested in saying more as you'd be able to guess who I am based on my old posts.

Damn, and I always thought you're in academia, lol. Unless that's one of your hobbies.

 

[Monocles]

A handful of people break 1M doing pure cash working 25 hours a week around here.

This right here. With earning potential of 1M+ and disciplined spending you can comfortably retire in <4 years out of training.

Sluox, I always wonder about patient expectations. Perhaps this is personal insecurity but I feel like *I* would never be able to provide the care that people "expect" when they shell out $800+ for a single hour. Clinically my outcomes in training have been fairly good, but I just worry about gaggles of angry rich people with burning pitchforks outside my practice, lol.

 

[vistaril]

This right here. With earning potential of 1M+ and disciplined spending you can comfortably retire in <4 years out of training.

Sluox, I always wonder about patient expectations. Perhaps this is personal insecurity but I feel like *I* would never be able to provide the care that people "expect" when they shell out $800+ for a single hour. Clinically my outcomes in training have been fairly good, but I just worry about gaggles of angry rich people with burning pitchforks outside my practice, lol.

when you are charging > 800 an appt for an hour, you have to think of yourself less as a psychiatrist and more as just a business entity/idea where you are marketing yourself to them. At that point, whether you are a psychiatrist or psychologist or self help guru or motivational expert or life coach or whatever is really irrelevant. After all, what are they paying you 1000 bucks for the appt for? It's certainly not to get that prescription of celexa or xanax or whatever....they can pick that up anywhere with their insurance and an np. No, they are paying you that sort of money because they believe you are somehow worth it....

in much the same way there are also plenty of life coaches and motivational gurus in certain locales who are marketing to wealthy clients and charge similar rates.

I'm similar to you in that even if I lived somewhere where this was possible, and I even if I was able to attract 1000 dollar an appt patients(I doubt I could), I still wouldn't feel comfortable doing it. The patient to patient pressure would just be too much....always wondering if I am doing a good enough job given what they are paying. Always thinking "how can I give them this extra value vs the guy who will see them for their 35 dollar copay".....I wouldn't want those worries.

 

[dl2dp2]

Sluox, I always wonder about patient expectations. Perhaps this is personal insecurity but I feel like *I* would never be able to provide the care that people "expect" when they shell out $800+ for a single hour. Clinically my outcomes in training have been fairly good, but I just worry about gaggles of angry rich people with burning pitchforks outside my practice, lol.

We discussed this in other threads but perhaps it's worth re-iterating. People with resources are easier to work with than people who don't. In my experience, the most entitled patients are clinic Medicaid patients who have no skin in the game in their own recovery. People who pay between $300-$500 per 30-min session are not "rich". They are merely upper 10%. This is also not all that unusual--this is around the ballpark of FAIRHealth 99214+90833. Remember 10% of household earn around 160k, and have about 1M+ net worth. Also, my practice has very few retirees.

The "quality" of care is just spending time explaining clearly the diagnosis and logic behind it, side effects and pros and cons of various medications, etc, or just explain and say I do this type of psychotherapy which is evidence-based, and I follow this manual and it'll take X months. A 55-year-old senior executive or a physician would much *much* prefer someone intelligent and well trained to do a standard manual-driven CBT course than spend 10 more hours finding a highly variable quality therapist who charges $35 co-pay. I mean, wouldn't you? I know I would.

People with top 1% of net worth (i.e. >~10M--this threshold is higher where I am) don't [usually] go to people like me--I had maybe a handful of patients like this. They usually go to very senior clinicians who charge > $1k per hour. This is more unusual, but just not all *that* unusual. There are literally 3 MILLION people in the US with a household net worth > 10M. They are also not "crazy" as some character from "Dallas" or something. Imagine a typical successful business owner or C-level executive of a large company in his or her late 50s. That's it.

A lot of common SDN assumptions do not reflect the realities of real-world cash PP, IMO.

I'm similar to you in that even if I lived somewhere where this was possible, and I even if I was able to attract 1000 dollar an appt patients(I doubt I could), I still wouldn't feel comfortable doing it. The patient to patient pressure would just be too much....always wondering if I am doing a good enough job given what they are paying. Always thinking "how can I give them this extra value vs the guy who will see them for their 35 dollar copay".....I wouldn't want those worries.

I don't think this is what it is. I think it reflects the overall market reality. I rarely think in this way and don't do anything unusual in terms of marketing. There are just not that many private practice psychiatrists. I feel zero pressure in terms of competing against people who charge $35 co-pay. I also don't really really think people care if they pay $35 vs. $350 for a med check. This aspect is *irrelevant*. Your intuitions are totally off. NPs here charge $100-$150 per visit. It's very hard to find an independent practice that takes insurance. Insurance usage is associated with large HMOs, and they don't build very large behavioral health groups (which to me is interesting... why not and squeeze all of us out? It just doesn't happen). I think the bottom line is behavioral health is still peanuts vs. the real rainmakers like subspecialty surgery. Your revenue cap out by market forces between 1-1.5 and not a lot of ancillary streams. And people in PPs don't work that hard. HMOs don't care about you.

 

[clozareal]

Also with cash pay private practice, don't forget that some people have amazing out-of-network insurance coverage that will pay for 80-100% of mental health outpatient costs so long as you provide a superbill. So in reality, they could pay however much they want and need to only meet their deductible to have the insurance reimburse most if not all of it.

 

[Stagg737]

lol....same as I said to the other guy- show me these practices where the nps are doing unsupervised PCIs....

Nowhere would actually advertise that NPs are doing that other than to nursing schools. What patient would ever openly ask for this to be done by an NP as opposed to a physician? I saw an article about it a couple years ago about this becoming a trend in the UK with one NP having done over 100. Wish I had saved the article as this has come up more times than I'd ever wanted it to. If I can find it again, I will. You're in PPP though, right? If so, you should have access to that info...

Honestly, I don't understand why this is so hard to believe though. There are ICUs completely run by NPs without any on-site or even in-area physician supervision. Who do you think is performing acute bedside procedures to these patients?

This right here. With earning potential of 1M+ and disciplined spending you can comfortably retire in <4 years out of training.

Sluox, I always wonder about patient expectations. Perhaps this is personal insecurity but I feel like *I* would never be able to provide the care that people "expect" when they shell out $800+ for a single hour. Clinically my outcomes in training have been fairly good, but I just worry about gaggles of angry rich people with burning pitchforks outside my practice, lol.

What a silly thing to worry about. The 1% would never touch a pitchfork, they'd get their maids and butlers to do it for them.

 

[psyguru]

As a forensic psychiatrist with an expert witness practice, I have no worries about a mid-level encroachment. I don't believe NPs would be doing an Insanity evaluation or a PI case. Also I work in an academic setting clinically and am not worried about being replaced by an NP.

 

[vistaril]

Nowhere would actually advertise that NPs are doing that other than to nursing schools.

so I guess the answer is you can't....gotcha.

 

[vistaril]

I don't think this is what it is. I think it reflects the overall market reality. I rarely think in this way and don't do anything unusual in terms of marketing. There are just not that many private practice psychiatrists. I feel zero pressure in terms of competing against people who charge $35 co-pay. I also don't really really think people care if they pay $35 vs. $350 for a med check.

this is crazy, imo. You're already dealing with patients who have made the choice to spend 350 dollars on a med check, so of course that skews things. The vast majority of people in my experience very much care about a 315 dollar difference.

You reference people who are at that 10% cutoff and make 160k. People who make this(unless they are young single people with no kids) are very much 'watching their pennies'. This isn't a lot of money. If someone makes 160k their take home pay every 2 weeks is going to come to about 3800...give or take. I make way way more than that and I can assure you I would care about that difference....it's why I go to a psych who takes my insurance and my copay is 30 dollars.

The idea that most don't care if they spend near 10 percent of their every 2 weeks take home on what you describe as a med check is hard to fathom.

That said, I'm well aware some people do it. I don't have any reason to doubt you get 7-800 an hour. But we have data that break down these things.....most outpt psych practices in this country still take insurance. The percentages differ a little, but I haven't seen one report yet that suggests that nationally cash pay outpt practices are the majority. So then you have a minority of cash pay outpt practices, and within this minority most are charging much less than 800-1000 dollars an hour(or even 350 for a 30 minute f/u). When I was thinking of opening a practice I pulled up literally hundreds of practices in attempt to learn, and I just didn't see many who were charging at that level. Maybe those practices are less likely to advertise. but psychs in general aren't undercover....most people in the field locally know who all the other psychs are.

Most of the practice websites I see for psychs who do cash pay outpt are charging like 300-350 for a 60 minute new appt and then proportionally less for 20 and 30 minute f/u appts. Id be curious to see all these 1000 dollar an hour practices and read about them. I'd be especially curious to see a link to 1000 dollar an hour practices in places like Nashville, tn or Jacksonville, Fl or Greensboro, NC or any places like this. I think cities like that are a fairly good representation of where a lot of people and psychiatrists live, and I haven't been able to find any practices that charge those sort of rates....hell even charlotte, NC. Where are the 1000 dollar an hour psychiatrists there? Are they all hiding or in witness protection?

 

[Stagg737]

so I guess the answer is you can't....gotcha.

Cherry-picking sentences that are irrelevant to the argument is not a good way to convince people you know what you're talking about...

Do a basic google search, there have been pro-nursing studies with nurses performing PCIs with supervision going back to the 90's. Still looking for the article I saw, but here's one from medscape with an ARNP in the UK doing them independently in 2016: Coronary Angiography Not Just for Docs

 

[clausewitz2]

Cherry-picking sentences that are irrelevant to the argument is not a good way to convince people you know what you're talking about...

If Vistaril were interested in convincing anyone of anything he has made a very odd series of choices.

 

[dl2dp2]

Where are the 1000 dollar an hour psychiatrists there? Are they all hiding or in witness protection?

That is rare. I admitted it as such. Somewhere between $500 and $1000 an hour is not that rare. Charlotte NC is a market I know well, and no, it's not $300 an hour. NPs are charging $150 a piece in NC. LOL And you can barely find people. Try finding an independent psychiatrist closer to Taga Cay or Davidson...

 

[starri]

DOs are way up there too....

The absolute nerve os us...

 

[FlowRate]

Meanwhile, I'm watching the college admissions scandal documentary on Netflix and this one dude says that a likely unqualified independent college counselor will run you $200-300 per hour and a legit ICC is $500-1000.

If you can charge that much to proof some rich kids' college essays...

 

[J ROD]

No matter what you do in life there is competition. Most times you are going to be better at your job if you enjoy it. In theory, you will be doing this many years.