Is the market for Psychiatry going down?

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Hi,

Given proliferation of psych NPs, it seems that they are overtaking this field like family medicine through sheer numbers. In fact, there are more psych NP graduates than any other field. It also seems that PP has been deeply affected by these trends. What's your perspective on the future of psychiatry?

 

[comp1]

I can't imagine any field has a better outlook. I don't know about private practice in specific. That kind of headache is never something I even considered. However I can tell you that employers are desperate pretty much everywhere, for both MDs and NPs. We don't get a lot of managers and supervisors in the deep trenches of hiring and recruiting posting on this board. Instead people tend to go with vibes about things like AI and midlevels, but I can tell you in reality the need is insatiable. I don't see this changing during a recent graduate's career. Also, dual family/mental health training is a lot more common for NPs than MDs, so that might be why you are seeing the numbers you are.

 

[Sushirolls]

I disagree with insatiable.
I would discourage pursuit of psychiatry.
Just because there is a job doesn't mean it's one you want to work or will have satisfaction with.
So many other variables are afoot, that I'd discourage now med students from going into Psychiatry.
As my kids age up, I'm going to point them far away from medicine.

I'm in middle of nowhere the type of place where FM is king and they practice more full throttle. As result they seldom refer, and believe they can do it all. Unfortunately not true, and when I do see their patients, they should have seen me years ago, and the Psych ARNPs essentially, I am doing clean up mess fixing. But that doesn't truly equate to a service that's valued or wanted. Even when in bigger metros, PCPs will only refer within their system, and not out, so they'll have a 6-12 month wait, despite PP psychiatry in the same community able to get people in 1-8 weeks.

Psychiatry is also undergoing the wRVU inflation similar to radiology 10-15 years back, where the volume kept going up and up to make XYZ.

Long story short, stay away from Psychiatry unless you have some affliction of "I can only be happy doing Psychiatry."

 

[clausewitz2]

I disagree with insatiable.
I would discourage pursuit of psychiatry.
Just because there is a job doesn't mean it's one you want to work or will have satisfaction with.
So many other variables are afoot, that I'd discourage now med students from going into Psychiatry.
As my kids age up, I'm going to point them far away from medicine.

I'm in middle of nowhere the type of place where FM is king and they practice more full throttle. As result they seldom refer, and believe they can do it all. Unfortunately not true, and when I do see their patients, they should have seen me years ago, and the Psych ARNPs essentially, I am doing clean up mess fixing. But that doesn't truly equate to a service that's valued or wanted. Even when in bigger metros, PCPs will only refer within their system, and not out, so they'll have a 6-12 month wait, despite PP psychiatry in the same community able to get people in 1-8 weeks.

Psychiatry is also undergoing the wRVU inflation similar to radiology 10-15 years back, where the volume kept going up and up to make XYZ.

Long story short, stay away from Psychiatry unless you have some affliction of "I can only be happy doing Psychiatry."

I have to hard disagree here. Where I'm at the private practice psychiatry market remains very robust and we are a mid-size city that has some really gargantuan major hospital systems and a sprawling academic psychiatry empire. PCPs definitely do not refer exclusively within their own system and I would suggest therapists and psychologists are a better referral source anyway.

I do think it is probably a sound idea to develop a niche of practice that you particularly like, even if only for marketing purposes, but if you are choosing something you actually like to do it will tend to reduce your risk of burnout as well. Look around and see what kind of psychiatrists you're not able to find in your area and figure out whether any of those gaps are areas you'd be interested in practicing in. It could change, but I think not being able to get in patients is a problem of very sparsely populated areas (sorry Sushi) and people doing very generic undifferentiated stuff.

 

[FlowRate]

I can't imagine any field has a better outlook. I don't know about private practice in specific. That kind of headache is never something I even considered. However I can tell you that employers are desperate pretty much everywhere, for both MDs and NPs. We don't get a lot of managers and supervisors in the deep trenches of hiring and recruiting posting on this board. Instead people tend to go with vibes about things like AI and midlevels, but I can tell you in reality the need is insatiable. I don't see this changing during a recent graduate's career. Also, dual family/mental health training is a lot more common for NPs than MDs, so that might be why you are seeing the numbers you are.

I'll push back a little on the idea of demand being nearly universally high.

We used to have difficulty filling a few years ago but we're fully hired currently. I think it helps to have one of the overall most attractive work and compensation packages of employers in this popular and large metro. But I was actually doing some searching to see other listed jobs in the area and the other employers that compete with us on balanced quality and pay also seem to no longer be hiring psychiatrists. The remaining offerings are things like Talkiatry and a semi-shady TMS group.

Aside from us, most employers in the area seem to have a ratio of between 1:4 and 1:20 MD's:NP's and expect some degree of supervision of those midlevels, although midlevels have independent practice here.

On the compensation side: High level survey data I have access to (blend of MGMA and one other; blend of gen psych + subspecialties) saw no change in psych comp between their 2023 and 2024 surveys, whereas the rest of medicine saw an increase in comp, averaging around a 4-5% increase. 2022-2023 psych saw ~2% increase but the average in medicine saw a 4-5% increase. I think we had a couple of bigger jumps 2020-2022 but haven't kept pace since.

While supposedly psych is still one of the most in-demand specialties, I wonder if we're becoming similar to a lot of other specialties in terms of demand being locale specific and isolated to smaller/more rural locations--previously psych demand was true almost everywhere. I think the proliferation and increasing acceptance of NP's must contribute at least some to that phenomenon.

I'm not very plugged in to the private practice world in this area. I find it interesting that there actually aren't a ton of well-marketed solo private practices which I take to mean that people don't have to try very hard to fill. I think insurers prefer and are used to negotiating with larger groups, however. Almost all of the medium sized groups (10-40 "providers") are heavily NP (either 100% NP's or one MD medical director and the rest NP's.)

While I think there will always be demand for rigorously trained psychiatrists who practice either niche or true full spectrum (read: complex/high risk/severe) psychiatry, it's also simple supply and demand that the proliferation of psych and primary care NP's will take at least the easier bread and butter stuff. And make a harder mess of the rest of it for when those patients finally filter to us.

 

[MedMan80]

Will we be out of a job? Probably not as our experience and education does make a difference vs the regular NP. But the fast majority of patients cannot differentiate between a psychiatrist and a NP and infact call their NP's psychiatrists and doctors..so alot of the bread and butter outpatient psychiatry is lost to them unfortunately..will this cripple the field? no, but will it affect things..yes..

 

[Stagg737]

my experience is similar to Clause. My C/L service is constantly referring to outpatient docs outside of our major hospital system because it’s a minimum 6 month wait to be seen, often closer to a year. We were for mostly to the community mental health centers, but if any private practice reached out to us and said they wanted referrals from us we could probably fill their entire panel in about a month.

My outpatient experience for rural areas is also very different from Sushirolls’ experience. I cover about half a state via telepsych and have at least 11 PCP offices that refer patients to me just for consultation. I only do about five or six hours of clinical week so my hours are limited, but I am constantly 40 to 50 patient referrals deep and I’ve gotten to the point that I only accept about 50% of consults that are sent to me. Ironically, primary NPs are the ones who I get most of my referrals from as them and patients aren’t happy with the paycheck care from their local CMHCs which are almost exclusively psych NPs.

Those situations may not be the case everywhere, but frankly there is plenty of opportunity in my state and if I ever left my current position I’m confident I would have no problem whatsoever finding a job or creating my own private practice.

 

[FatherPsychiatry]

Where I'm at (large metro, government job), psychiatry jobs are a bit harder to come by than five years ago when I came out of training. When I started, most of the big government gigs were full of contractors, and if you wanted to join as an employee you were guaranteed a spot and could even bargain up to a higher/highest salary step. Now, many of the spots have been filled with employees, and it is much more difficult, if not impossible, to push for a higher starting salary.

The older guys/gals tell me these shifts have happened before and will likely happen again. Some big leadership change and many psychiatrists quit, they start making some changes including higher salaries and people start coming back, then COVID or something happens and a lot of people leave and then people start coming back again etc.

The big change now I see is NPs. Not really a thing where I worked >5 years ago but now they are starting to fill in the "gaps". I can see why employers like em - they push the meat through (all the employer really cares about), at 1/3 or 1/4 the cost of a psychiatrist.

 

[DOswag]

I'm in a big city in the South outpatient, we do have NP's in our clinics but even with that, our schedules are packed and it's still difficult to get in to see psychiatry due to demand. The biggest thing that bothers me with psychiatry is it seems everyone self diagnosis adhd or autism and we have a constant demand for evaluations of this type.

"Oh you made straight A's all the way through your grad program but now you're a mother of 4, homeschooling, working from home, have a side business and you feel you can't concentrate? Yeah that's not adhd. Oh you saw a tik tok video and your sister's best friend tried someones adderall and it worked great for them so you tried one and it worked for you? Yeah still not adhd."

 

[Stagg737]

I'm in a big city in the South outpatient, we do have NP's in our clinics but even with that, our schedules are packed and it's still difficult to get in to see psychiatry due to demand. The biggest thing that bothers me with psychiatry is it seems everyone self diagnosis adhd or autism and we have a constant demand for evaluations of this type.

"Oh you made straight A's all the way through your grad program but now you're a mother of 4, homeschooling, working from home, have a side business and you feel you can't concentrate? Yeah that's not adhd. Oh you saw a tik tok video and your sister's best friend tried someone’s adderall and it worked great for them so you tried one and it worked for you? Yeah still not adhd."

Patient: “I’m a socially awkward female so I must be autistic”.

Me: “That’s not really what ASD is…”

Patient: “Well autism is just different in girls.”

Me:………

Seriously though, I feel the pain here too. I recently just stopped taking ADHD and autism referrals altogether. Way too many patients with needs I can actually help without them demanding stimulants that their PCP won’t prescribe to spend time on these cases.

 

[DOswag]

Patient: “I’m a socially awkward female so I must be autistic”.

Me: “That’s not really what ASD is…”

Patient: “Well autism is just different in girls.”

Me:………

Seriously though, I feel the pain here too. I recently just stopped taking ADHD and autism referrals altogether. Way too many patients with needs I can actually help without them demanding stimulants that their PCP won’t prescribe to spend time on these cases.

I've watched a few of these social media videos, many of them by NP's in mental health working on their social media influence, and all they do is give vague symptoms that are not specific to adhd or autism but then suggest "you may need to talk to your doctor about autism".

"Do you get cold when you go outside in 30 degree weather without a coat on? Do you get hungry when you haven't eaten in several hours? Do you sometimes get tired when it's late in the evening and it's time to go to bed? You may be an adult with undiagnosed autism."

My wife, who does have adhd, will sometimes send me videos like this and then I get kind of annoyed and tell her why none of the symptoms in the video are specific to adhd and could literally be anything in the DSM and then she gets annoyed at me...

 

[FatherPsychiatry]

Patient: “I’m a socially awkward female so I must be autistic”.

Me: “That’s not really what ASD is…”

Patient: “Well autism is just different in girls.”

Me:………

Seriously though, I feel the pain here too. I recently just stopped taking ADHD and autism referrals altogether. Way too many patients with needs I can actually help without them demanding stimulants that their PCP won’t prescribe to spend time on these cases.

I've watched a few of these social media videos, many of them by NP's in mental health working on their social media influence, and all they do is give vague symptoms that are not specific to adhd or autism but then suggest "you may need to talk to your doctor about autism".

"Do you get cold when you go outside in 30 degree weather without a coat on? Do you get hungry when you haven't eaten in several hours? Do you sometimes get tired when it's late in the evening and it's time to go to bed? You may be an adult with undiagnosed autism."

My wife, who does have adhd, will sometimes send me videos like this and then I get kind of annoyed and tell her why none of the symptoms in the video are specific to adhd and could literally be anything in the DSM and then she gets annoyed at me...

How do you all feel about AuDHD? Popping up all over my feeds.

 

[NeedAdvicelol]

Have you checked the psych NP reddits recently? Lots of people complaining about oversaturation and not being able to find a spot, let alone make 200k while WFH like how it was during COVID. They'd probably be the first to feel the squeeze, which I see starting to happen. Psych NP influencers need to stop showing off something that no longer exists. Its deluding people, creating more competition for everyone, themselves included. That said, opportunities do exist and you CAN find a job, even easily, depending on where you look. But the types of jobs that are readily available tend to be a meat grind with low money to volume ratio (cue underserved community centers, large for-profit telepsych corps, etc).

But what about the "psychiatry shortage" that everyone is screaming? That, my friend, is a Koolaid that has they continue to serve in medical school, in politics, in general society whatsoever that no longer applies. It was true in an era when NPs graduated less people than MDs on a yearly basis, when there were less than 1000 psych residency slots per year. Both are no longer true and has been for some time. There are shortages within psychiatry that do exist, but will continue to remain a shortage i.e. medicaid, frequently hospitalized high risk pts. I very rarely encounter psych NPs who work with them, runs too contrary to the 200k minimal work delusion they were peddled. All the surplus graduates seem to be piling into higher paying private insurance/cash pay low risk patient population and often you see an endless supply of services there.

 

[romanticscience]

How do you all feel about AuDHD? Popping up all over my feeds.

View attachment 414952

Shoot! Why did I not see this picture sooner? It would have saved me the countless hours over the past few decades understanding cognitive neuroscience!

 

[Merovinge]

Patient: “I’m a socially awkward female so I must be autistic”.

Me: “That’s not really what ASD is…”

Patient: “Well autism is just different in girls.”

Me:………

Seriously though, I feel the pain here too. I recently just stopped taking ADHD and autism referrals altogether. Way too many patients with needs I can actually help without them demanding stimulants that their PCP won’t prescribe to spend time on these cases.

This is seriously depressing when social media can corrupt things to the point that child & adolescent psychiatrists are not taking ADHD/ASD referrals. We are the terminal sub-specialists in those disorders.

 

[comp1]

Okay so I'm hearing that high paying complete work from home jobs where you are paid the same as working on site no longer exist. This is true. It's true for both NPs and MDs. It's also true in pretty much every occupation, including outside medicine. Further, we SHOULD be handling more complex and high risk cases than NPs and PAs. We have more training and are paid more! It's why we exist. All that said, high paying employment is still plentiful everywhere for both mental health NPs and MDs. Show me any metro area without an immediately available 40 hour/week psychiatry job that pays over $300k, to say nothing of the complete absence of MDs or NPs filling any of the literally thousands of rural mental health jobs available.

 

[Dr. Pookie]

I was recently solicited to supervise an NP for $350 a month. I couldn't believe it. No amount of money is worth my license, but $350. Holy...

 

[Merovinge]

I was recently solicited to supervise an NP for $350 a month. I couldn't believe it. No amount of money is worth my license, but $350. Holy...

I would counter with them punching you in the face and you paying them $200/month. Hopefully that would get the point across.

 

[comp1]

I do think these whole financial agreements where MDs are paid to provide some sort of oversight over a midlevel they don't actually work with on a daily basis shoulder to shoulder need to end. I'm a big proponent of PAs and NPs, but they should be in a setting where MDs are always easily accessible and where reaching out to each other as needed on a daily basis is all part of everyone's basic salaried employment. These bizarre separate agreements do no one any good. I don't think they're the majority or the future, fortunately.

 

[mistafab]

I really don't think the market is going down. I think the growth might be going down - I.e. the rate of growth is declining or even flatlining. So far though I think we're sitting pretty. I've kept my fingers in many pots to remain privy to salary and work changes in the market-force - the gettins' are still good. I still got a side gig recently and still was satisfied with my compensation there as a 1099. This is still happening readily and folks shouldn't need to feel stuck unless they want to.

 

[Stagg737]

This is seriously depressing when social media can corrupt things to the point that child & adolescent psychiatrists are not taking ADHD/ASD referrals. We are the terminal sub-specialists in those disorders.

I’m not CAP and I think there is only 1 CAP trained psychiatrist in the part of the state I serve. I’m talking about 100% adult consults though.

 

[HemeOncHopeful19]

This is seriously depressing when social media can corrupt things to the point that child & adolescent psychiatrists are not taking ADHD/ASD referrals. We are the terminal sub-specialists in those disorders.

Really sucks for legit patients who can’t get in for care because they get get lumped in with the TikTok trends.

I’m guilty of this myself at times when it comes to Eosinophilia or Mastocytosis, I see a referral on the desk and roll my eyes despite there being a few legit cases out there

 

[Candidate2017]

Further, we SHOULD be handling more complex and high risk cases than NPs and PAs. We have more training and are paid more! It's why we exist.

Nah, midlevels say they're equivalent to physicians. Let them see the complex, high risk patients too. If they want to play doctor, then let them catch that smoke too. And, we're not actually paid more because of our training. As a cognitive specialty, we produce based on volume. We're paid more because we're more efficient/see more patients.

I was recently solicited to supervise an NP for $350 a month. I couldn't believe it. No amount of money is worth my license, but $350. Holy...

It' actually worse. They can offer $0. More and more, I see job postings that require psychiatrists to supervise midlevels, regardless of whether midlevels are legally allowed independent practice.

I'm a big proponent of PAs and NPs, but they should be in a setting where MDs are always easily accessible and where reaching out to each other as needed on a daily basis is all part of everyone's basic salaried employment.

The problem is (1) midlevels don't reach out (they don't know what they don't know), (2) they bristle at any type of supervision because they believe they're equivalent to physicians, and (3) you can't supervise someone you can't fire; they work for the system and not for the psychiatrist. But, they are always ready to throw a physician under the bus, e.g., put your name on the chart. Trust me.

In sum, the power of psychiatrists is going down, irrespective of demand. If strong demand correlated with better working conditions, higher pay, and more respect, then K-12 teachers would be rolling in it. Matter of fact, increased demand for mental health services generally leads to more government interference, more "mental health" workers, more public advocacy, more lobbying from hospital CEOs, and more uneducated voices controlling what we actually do, to the point where we are actually marginalized. Hence, prescribers. And someone else reaps the trillions of dollars poured into the healthcare space.

 

[clozareal]

NP clinics for mental health is such poor quality care from an inadequate education system for PMHNPs. There's no way 1 MD can appropriately supervise 500 NPs (looking at your Circle Medical). It's like going to Temu expecting a quality product.

I don't think MDs compete at the same level of NPs. They are filling a tier that we're not equivalent to, which is okay. Some people want Temu (NP/PA mill with no supervision, all virtual, 10 minute visits or even just 5 minute phone calls with Google form check in, high caseloads, providers change ever appointment). Others want Walmart, others want Target, some want Nordstrom. High-level practices offer Neiman Marcus level services (direct access to psychiatrist, low caseload, high specialization, high complexity, high acuity, cash only, in person, longer visits).

I haven't seen a downward trend in my referral stream. If anything, it's even more. Some start with an NP, but then realize they're getting a service quality that is below the standard of care, then later decide they want a more specialized, physician-led approach. At that point, they're more prepared to invest in a higher level of clinical care.

Thankfully, many of the NPs in my area know when they're out of their depth and send those patients over to me. Many aren't aware which is dangerous in my opinion because it's harmful at worst and at best, delays appropriate level of care. I think collaborating with them to take more complex patients so that there can be the right level of care that aligns with their needs and values is important.

 

[Ahamis]

Nah, midlevels say they're equivalent to physicians. Let them see the complex, high risk patients too. If they want to play doctor, then let them catch that smoke too. And, we're not actually paid more because of our training. As a cognitive specialty, we produce based on volume. We're paid more because we're more efficient/see more patients.

Agree!
If psychiatrists are going to take mostly complicated/resistant cases in their case load, the field will become extremely heavy/unpleasant.
Are you going to be able to see 40 hours of patient contact when most of them are the complex cases?
I am not. The are few patients that bring such a negative energy that you can feel it for hours after they leave the appointment.

I have refused so many job offers because it was a requirement to supervise midlevels. It became a trend. The employers don't expect you to say NO.

 

[WolfBoy3000]

Want to be optimistic and still pursue psychiatry so very badly... but all of these points are simply too logical to ignore.. of course I'd like to believe I'm the exception and it'll all work out for me, but with NP palooza and AI apocalypse well on its way, it's feels impossible to hold onto that vision.

 

[Stagg737]

Want to be optimistic and still pursue psychiatry so very badly... but all of these points are simply too logical to ignore.. of course I'd like to believe I'm the exception and it'll all work out for me, but with NP palooza and AI apocalypse well on its way, it's feels impossible to hold onto that vision.

I mean, it depends on what you want to do in psychiatry. If you just want to make $400k doling out lexapro to a bunch of stressed out housewives 25 hours a week, then you're in for a bad time. The NP doom and gloom has been around for 15+ years. in 2012 when I was applying surgeons were telling me not to bother with medicine saying some of the same stuff you're hearing here.

Is the field going to look different in 10-15 years? Probably. I'd argue that COVID changed the landscape far more than NPs have. It's the unexpected that really causes the major changes. Sometimes for the better briefly (like work from home) until things "normalize". If you're really between 2 fields, then psych may not be the best options depending on what that other field is. Keep in mind, that until the past 5-7 years psych wasn't a "desirable" specialty. In 2015 average psych salary was barely $200k. 10 years later it's easily over $300k. What we're likely seeing with the lack of expansion and growth is probably the lull after a boom, not the death knell of our field.

So again, if you're of the mindset that psych was supposed to be the next derm and you could make bank doing whatever your want in the locale of your choice, then you need to temper those expectations. I still think that psychiatry has one of the widest variety of opportunities our of any field and that there will continue to be very solid opportunities for those willing to adapt and be flexible.

 

[TexasPhysician]

The outlook is certainly decreasing like many specialties.

When I opened my first clinic 10 years ago, I had 5 psychiatrists as competition within a small geographic region. 1 psych NP worked with one of those psychiatrists. In the same area, there are now 8 psychiatrists and 20+ psych NP’s competing. The population is not significantly changed. I don’t think I could be near as successful anywhere near as quick as 10 years ago.

This is a big problem for new grads wanting to quickly build a private practice in many areas. There is no longer a true “shortage” of psychiatrists. There is just an abundance of jobs that want to pay us poorly that complain loudly.

I don’t see this specific to psychiatry though. Urgent cares near me are mostly NP’s, many with 0 MD’s on site. Some ER’s are heavy on NP’s too. Some hospitalists are using 3+ NP’s while rounding. Unless there is a complaint, some patients admitted to medicine never see a MD. Derm clinics near me are all NP’s. The closest sleep medicine clinic is NP only. It is scary to think of my future health and how to achieve MD care.

 

[randomdoc1]

The market for healthcare is going down. Not just psychiatry. If you look at medicare rates, they are basically uncoupling from inflation. We're getting poorer. Add to that use of AI to multiply work forces, need less bodies. Add to that APNP and PAs. Add to that residencies churning out grads at a rate that is outpacing the growth of the American population. Saturation and depreciation. I've just learned to make income in different ways and invest. And sit back. I'm out! : P. I still practice medicine. I love it. But it's a hobby. I'm not counting on it in any significant way.

 

[comp1]

To all of the doom and gloom people above (with which I vehememently disagree), what field of medicine or occupation is somehow better? What has less competition, less overhead, requires less training and pays better for less work? If psychiatry is somehow not a good (great) choice, what is?

 

[NeedAdvicelol]

Okay so I'm hearing that high paying complete work from home jobs where you are paid the same as working on site no longer exist. This is true. It's true for both NPs and MDs. It's also true in pretty much every occupation, including outside medicine. Further, we SHOULD be handling more complex and high risk cases than NPs and PAs. We have more training and are paid more! It's why we exist. All that said, high paying employment is still plentiful everywhere for both mental health NPs and MDs. Show me any metro area without an immediately available 40 hour/week psychiatry job that pays over $300k, to say nothing of the complete absence of MDs or NPs filling any of the literally thousands of rural mental health jobs available.

I'm also sensing that the job outlook can be quite dependent on the locale. I am in a large metro area with "above average" desirability. When I do a quick scan of open job openings within a 50-mile radius, heres what I see (for physician roles):

30% of the openings are from some kind of large multistate equity-backed psych organizations (often telepsych). Tricky marketing because while they list their "location" as your city, its largely irrelevant due to the nature of the job. Definitely not the best bang for your buck. People I know who joined generally feel taken advantage of/underpaid for the amount of work. Also some can be quite shady with your pay - personally a no for me.

30% are inpatient openings or some role within a large hospital system. From what I've experienced, can range from quite good to bad, depending on the specifics of the contract/location/patient pop. Keep in mind good spots tend to be taken. It's usually the roles with higher turnover that tend to have openings.

30% opening are at places that for one reason or another perpetually have trouble filling (FQHCs, under-resourced safety net locations, etc). Its funny because I sometimes see the same listing open as a locums; if you convert the 1099 hourly pay vs. W2 salary for the same position, locums pays 50% more if we're talking pure $$.

The last 10% are jobs that worth looking further into i.e. excellent work-life for the pay, outpatient PP that give you lots of autonomy and support, academic roles where APPs/residents do the heavy lifting etc. I had applied to a couple of those back when I was on the hunt for jobs. Unfortunately, a lot of them all filled and just never took down their ads or were very competitive with many applicants.

Many years back when I was in med school looking at specialty prospects, the landscape looked quite different. Even jobs that were highly desirable had trouble filling and contributed to a larger share of posted openings than right now. For-profit telepsych was not really a thing, maybe 5% of jobs out there. The flavor of hospital-based opportunities was also different, in a way that gave more perks to psychiatrists. The only silver lining is that I think base salaries have trended up, but so has the workload across the board. Again, maybe its because my area that has become more saturated, but I do feel a change.

Before anyone says anything, I want to clarify: no we're not becoming EM, nowhere close. But definitely things are different now.

 

[DareGreatly]

The outlook is certainly decreasing like many specialties.

When I opened my first clinic 10 years ago, I had 5 psychiatrists as competition within a small geographic region. 1 psych NP worked with one of those psychiatrists. In the same area, there are now 8 psychiatrists and 20+ psych NP’s competing. The population is not significantly changed. I don’t think I could be near as successful anywhere near as quick as 10 years ago.

This is a big problem for new grads wanting to quickly build a private practice in many areas. There is no longer a true “shortage” of psychiatrists. There is just an abundance of jobs that want to pay us poorly that complain loudly.

I don’t see this specific to psychiatry though. Urgent cares near me are mostly NP’s, many with 0 MD’s on site. Some ER’s are heavy on NP’s too. Some hospitalists are using 3+ NP’s while rounding. Unless there is a complaint, some patients admitted to medicine never see a MD. Derm clinics near me are all NP’s. The closest sleep medicine clinic is NP only. It is scary to think of my future health and how to achieve MD care.

I think this take is pretty accurate but a bit too bleak. There are just a lot of NPs out there - and a lot of them practicing in specialized settings without much experience or training to back it up. That said, public awareness of what NPs/PAs are is definitely increasing. I would say the average patient now knows that everyone they see isn't a doctor - there are MDs and midlevels. I have more and more patients wanting to see an MD. There will be saturation point - and this is partly related to the bedside nursing shortage - at some point it doesn't make financial sense to go from RN to NP. Unfortunately, the trend is a bifurcation in quality of care (reflective of the growing disparity in our country generally). Patients will continue to learn that you can't default to trusting that a "provider" is high quality. I think this level of skepticism will be mostly directed toward midlevels. It also dovetails with how PE-backed places market as specialists in a particular area of psychiatry and then just have midlevels rendering the care. Overall, it makes healthcare even more confusing to navigate.

I'd say as psychiatrists, we are going to be just fine, though. This is not a new trend, and mental health treatment demand has increased a lot in the past decade. Around me, in a decent-sized city with multiple academic institutions and a number of hospitals - there are always open inpatient roles, outpatient employment is easily found, and it's not hard to set up a private practice. Will cash pay practices become untenable in the future? Maybe. Certainly the days of throwing your shingle up and having unlimited demand while charging cash for simple cases is no more (if they ever did exist). Could employed salaries be depressed because NPs exist? I think so, but I would imagine if there were not NPs/PAs and no significant expansion of residency slots, the volume of patient care could be overwhelming. Overall, I wouldn't shy away from psychiatry because you're worried about the specter of AI or midlevels. Those risks touch every field of medicine. AI is going to affect every industry outside of medicine. At the end of the day, I think a lot of things would have to break the wrong way in the next 30 years to not be able to maintain (at bare minimum) an insurance-based private practice.

 

[MedMan80]

I was recently solicited to supervise an NP for $350 a month. I couldn't believe it. No amount of money is worth my license, but $350. Holy...

A practice wanted me to supervise an NP and also become their medical director for that much 😀

 

[FlowRate]

barely $200k. 10 years later it's easily over $300k.

$200k in 2015 is $270k now. We have seen some real increase, probably thanks to demand and psychotherapy add-on codes. But...

To all of the doom and gloom people above (with which I vehememently disagree), what field of medicine or occupation is somehow better? What has less competition, less overhead, requires less training and pays better for less work? If psychiatry is somehow not a good (great) choice, what is?

I think you defined yourself into a narrow view of what fields of medicine are better. Being a MOHS derm surgeon was never in the cards for me, but I'd say they probably aren't grinding "real" surgeon hours and are earning $800k/yr. Sleep med still earns more than we do, at least in the salary surveys, and is arguably an easier field in many ways.

 

[Atreides]

$200k in 2015 is $270k now. We have seen some real increase, probably thanks to demand and psychotherapy add-on codes. But...

I think you defined yourself into a narrow view of what fields of medicine are better. Being a MOHS derm surgeon was never in the cards for me, but I'd say they probably aren't grinding "real" surgeon hours and are earning $800k/yr. Sleep med still earns more than we do, at least in the salary surveys, and is arguably an easier field in many ways.

MOHS is a different world lol. My friend in the Midwest is breaking seven figures with a pretty standard derm schedule. Normal employee, doesn’t own his own practice or anything.

 

[comp1]

I don't think anyone is recommending against derm. So if you have a choice between psych and derm and you can actually handle the procedures, go for derm. Just the idea that psych is competing with derm really shows how great psych and its future are.

 

[Stagg737]

MOHS is a different world lol. My friend in the Midwest is breaking seven figures with a pretty standard derm schedule. Normal employee, doesn’t own his own practice or anything.

I'd say that's pretty abnormal even for derm. One of my colleague/friend's spouse is derm in the midwest working a typical schedule and does really well, but not close to 7 figures well (probably closer to $700k/yr).

Also, derm pays so high because they're billing 99213/4 upwards of 25-30x or more per hour. When you bill for 2-3x the wRVUs that a psychiatrist does, it makes sense that you're earning 2-3x as much and that's not even including procedural codes. I rotated with a psychiatrist back in 2017 who was seeing 35-40 patients per day in their outpatient clinic and they were making well over $600k/yr, probably around 7 figures from the hints they dropped.