Is this job worth it?

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Pretty burnt out with current position, the liability seems high and I just wanted some outside opinions from other psychiatrists if I should suck it up or cut my losses and get out...

Compensation: straight salary, 300k. no minimums for productivity or productivity bonuses.

Supervision: I have four midlevels under me and theyre talking about putting a fifth...some of them are ok, others are horrendous... I had an issue with one recently where they werent checking the controlled substances database before dishing out benzo refills and that was a complete mess to sort out...I basically supervise two different clinics, and one of those clinics was run by a PCP doing psychiatry (before he retired and now his patients are seen by a midlevel I supervise), and they had probably 1/3 of their patients on benzos plus/minus stimulants. Example: patient states they cant sleep and klonopin helped in the past. Solution? prescribe klonopin. Also in my state midlevels cant practice independently and require physician supervisor.

pt population: uninsured/medicaid. Most are on the higher acuity side with multiple medical issues, polysubstance abuse, etc.

number of patients: 2-4 new ones, 8-12 f/u on average.

My main issue I think is the number of midlevels makes me lose sleep at night. I just dont trust them enough, i do a ton of chart reviewing but I still constantly worry. I think five is an absurd number of midlevels for one person to manage, heck I think above 3 is too many...Also admins are kinda rude, and generally don't listen to feedback well. Seems to be a high staff turnover rate as well.

Thoughts?
 
DrAmazingishere said:
My main issue I think is the number of midlevels makes me lose sleep at night. I just dont trust them enough, i do a ton of chart reviewing but I still constantly worry. I think five is an absurd number of midlevels for one person to manage, heck I think above 3 is too many...Also admins are kinda rude, and generally don't listen to feedback well. Seems to be a high staff turnover rate as well.

Thoughts?
Click to expand...
It sounds like these are pretty big issues that won't just resolve at some point. Why are you considering this job? What do you like about it?
 
HELL NO..4 midlevels!? You shouldn’t have to see any patients supervising that many is a full time job!! Think about this..by supervising them you’re essentially training your replacement so that they get smarter and more experienced so in 5 years they know enough to not need you anymore…for 4 replacements that’s worth minimum 300k per year..never mind the liability of the entire thing

Edit: I just read that admin is rude..leave and don’t even think about it..on top of you doing this insane service for them they are RUDE!? Are you kidding me?
 
Bad job in my opinion. Your salary would be fair for just the patients you see on your own.

Even ethically, I don't think these kind of practices should exist.
 
I am wondering what control you have as a supervisor of mid levels. If they are not prescribing responsibly and are not adjusting their practice to your feedback, what options do you have? What is your ethical responsibility? Refuse to supervise the worst ones? Report to the boards? Just quit?
 
Yeah no thanks. That’s all I gotta say about this.

You can do/work with a private practice and contract out to an FQHC 1-2 days a week if you really still want to see Medicaid patients and still probably make around 300K. Without having to insanely supervise 4 midlevels.

Even with Medicaid patients the amount of money you’re bringing in by supervising 4 midlevels is going to be higher than your salary.

This is the way of the world for FQHCs now unfortunately. It’s similar with public assistance primary care offices where it’s pretty much a bunch of NPs/PAs to cut costs. Medicaid patients don’t have much of a say in who they get to see, uninsured patients are lucky to see anyone at all. An army of the crappiest/new grad midlevels with 1 psychiatrist “collaborating”. I wouldn’t get caught up in the death spiral of FQHCs personally.
 
Liability aside, does providing this type of care to human beings not seem like an issue? I frequently hear people say things like "if I don't do it, they will just find someone worse then me to fill the position" which sounds an awful lot like drug dealers who say "if I don't sell it to them, someone else will"...

Different strokes for different folks but I don't see how this follows the principal of first do no harm as a physician.
 
Yikes! Aside from the workload being too many patients, the additional work and liability issues of the midlevels raise many red flags. What is your daily number of pts that you have to supervise and sign off on?

In this market you could probably get 300k easy just for your own patients... I personally don't like being financially liable for others' clinical work, so they'd have to pay me at least 50k for each NP to supervise, and 100k for the bad one lol. Tell them they can take it or leave it.


EDIT: As I as reading this I am getting more and more upset. OP this is such an extraordinary uncompensated financial risk and the fact that your organisation is putting this on you for peanuts is CRIMINAL. Imagine your benzos guy handing out controlled substances like candy and your patients end up having a lethal OD. You would get torn apart in court and could be on the hook for millions even beyond your malpractice insurance. I would drop this job yesterday.
 
General estimates:

Average Medscape salary for a psychiatrist: $278k
Average caseload: ~30-40hrs/week
Average hourly: $270
Average cost for an NP to hire a supervising physician: $15k-40k/yr
Average out of pocket malpractice suit cost: $25k
Average psych NP salary: $120k.
Average psych NP hourly: IDK, $120/hr.

Let's say you are taking a "normal" case load, which grosses $388k. Your employer profits $88k from your work, less ancillary overhead. They also get supervision, which would be worth ~$60k on the open market. The mild "raise" in your salary saves your employer $38k/yr in supervision costs. But then those 4 psych NPs gross $600-4700k/yr, are paid ~$500k, producing $100-200k in profit for your employer.

Broad strokes: your presence profits them $288k (your revenue, plus your NPs profits, less your salary).

They could hire a supervising physician at $60k/yr, but they would only make $140k in NP profits.

Know your worth.
 
Why did you take this job? Are you restricted due to residency status?
 
Thanks for the advice/perspectives this was really useful.

So its a large, community practice that receives a good deal of government grants. I took the job because in the middle of my job search, I had a big life event happen (was dealing with quite a bit), and was on my own with no family support (they live a good distances away) trying to work out life circumstances and at the time it seemed like an ok job. Also this was my first job as an attending so tbh I had no idea what to expect.

What happened was while I was there, one provider (the PCP) quit and they started piling stuff on me.

I do a ton of chart reviews, at least 40 a day and go behind the midlevels to fix stupid stuff they do, but ugh in a way I almost want to be in a state where they practice independently so I dont have to work with them anymore. Most are receptive, but others can be a struggle to get them to understand.

At first I felt guilty, because the patient population is very sick and im also the only clozapine provider, for the most part but then I stopped feeling that way when i realized there were sick patients everywhere with more appreciative facilities..

But yes I will more likely take the advice...
 
DrAmazingishere said:
Thanks for the advice/perspectives this was really useful.

So its a large, community practice that receives a good deal of government grants. I took the job because in the middle of my job search, I had a big life event happen (was dealing with quite a bit), and was on my own with no family support (they live a good distances away) trying to work out life circumstances and at the time it seemed like an ok job. Also this was my first job as an attending so tbh I had no idea what to expect.

What happened was while I was there, one provider (the PCP) quit and they started piling stuff on me.

I do a ton of chart reviews, at least 40 a day and go behind the midlevels to fix stupid stuff they do, but ugh in a way I almost want to be in a state where they practice independently so I dont have to work with them anymore. Most are receptive, but others can be a struggle to get them to understand.

At first I felt guilty, because the patient population is very sick and im also the only clozapine provider, for the most part but then I stopped feeling that way when i realized there were sick patients everywhere with more appreciative facilities..

But yes I will more likely take the advice...
Click to expand...
You are not responsible for the woes of the healthcare system. You don't fix all of the USA's issues by being a superhero doc, it only leads to burnout. You are responsible for the care you provide and the midlevels you are to supervise. Best of luck on the job search, since the bar is set so low, I have no doubt you will find a much better setup.
 
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bad deal. Move on if you can. I recently had an issue with one of NP. I was working on meds for sleep on patient. I changed the medication. They dc it without my knowledge. Couple days go by and I think they are getting this medication. I was changing another medication and noticed the sleep medication was not there. Search EPIC and find NP dc it. I ask them about it. Say I do not know, then says I did not do it. I confront them and show it plainly on EPIC.

Some background. I am about 20 years younger, they have about same years psychiatry experience as myself. In my second year as attending. NP was family medicine for 30+ years. From day 1, always had issue with myself as attending likely due to age. NP has been there 4 years before me.

Well, I get called by medical director who is her age. I basically get reprimanded for talking to her and making her upset. I expressed as MD she is working under my license, I make the medication calls. Director says well, they have say too and basically says we should work it out. I was like hard to work out when they just dc it and say nothing. In meeting she admitted to dc. I was so pissed I about quit right there but I need money to live. So, now she basically works on another floor under him and I do not supervise her anymore as I refused. He said ok and I basically took a less role and money in this deal.

I mainly like my job and what I do but they also have NP been there for 30+ years in charge of inpatient unit and in admin. She basically calls me at times and bullies me into taking social admits that truly do not meet inpatient criteria. I am over inpatient units as MD but in some weird way she is not over me but is. I refused one time to accept and got called by CEO and told that pt is coming to unit. I really do not care if another MD tells me higher up I have to take the patient. I just do not think a NP should be bullying me to accept patients that are basically social admits. I understand her bosses on her ass. But still......I am the MD.

Money is good and job is fairly easy. But, I feel like a resident again in many ways.

Just wanting some advice, to vent, and thoughts? It had been bothering me for weeks.....
 
J ROD said:
I mainly like my job and what I do but they also have NP been there for 30+ years in charge of inpatient unit and in admin. She basically calls me at times and bullies me into taking social admits that truly do not meet inpatient criteria. I am over inpatient units as MD but in some weird way she is not over me but is. I refused one time to accept and got called by CEO and told that pt is coming to unit. I really do not care if another MD tells me higher up I have to take the patient. I just do not think a NP should be bullying me to accept patients that are basically social admits. I understand her bosses on her ass. But still......I am the MD.

Money is good and job is fairly easy. But, I feel like a resident again in many ways.

Just wanting some advice, to vent, and thoughts? It had been bothering me for weeks.....
Click to expand...

The frustration with admin at inpatient centers is fairly common. I worked at an addiction center that had multiple locations. They would track detox days and show me months in which I had fewer detox days. I’d ask if they wanted me to increase those days. They would say yes and then complain that detox days weren’t getting covered. You can’t always make them happy.
 
my main issue is with NP thinking they can tell MD what to do and my director basically backing them. Probably why they are not able to keep MD. I know of 7 that have left within 4 years. Two recently. Basically every MD except director. since 2016 when he took over.
 
J ROD said:
bad deal. Move on if you can. I recently had an issue with one of NP. I was working on meds for sleep on patient. I changed the medication. They dc it without my knowledge. Couple days go by and I think they are getting this medication. I was changing another medication and noticed the sleep medication was not there. Search EPIC and find NP dc it. I ask them about it. Say I do not know, then says I did not do it. I confront them and show it plainly on EPIC.

Some background. I am about 20 years younger, they have about same years psychiatry experience as myself. In my second year as attending. NP was family medicine for 30+ years. From day 1, always had issue with myself as attending likely due to age. NP has been there 4 years before me.

Well, I get called by medical director who is her age. I basically get reprimanded for talking to her and making her upset. I expressed as MD she is working under my license, I make the medication calls. Director says well, they have say too and basically says we should work it out. I was like hard to work out when they just dc it and say nothing. In meeting she admitted to dc. I was so pissed I about quit right there but I need money to live. So, now she basically works on another floor under him and I do not supervise her anymore as I refused. He said ok and I basically took a less role and money in this deal.

I mainly like my job and what I do but they also have NP been there for 30+ years in charge of inpatient unit and in admin. She basically calls me at times and bullies me into taking social admits that truly do not meet inpatient criteria. I am over inpatient units as MD but in some weird way she is not over me but is. I refused one time to accept and got called by CEO and told that pt is coming to unit. I really do not care if another MD tells me higher up I have to take the patient. I just do not think a NP should be bullying me to accept patients that are basically social admits. I understand her bosses on her ass. But still......I am the MD.

Money is good and job is fairly easy. But, I feel like a resident again in many ways.

Just wanting some advice, to vent, and thoughts? It had been bothering me for weeks.....
Click to expand...
This is really a personal decision to be honest, I don’t think I could be at a place where the ceo is calling me and dictating my patient care and certainly not an NP, however I definitely know people who are ok with that and neither is right or wrong it’s just a personal choice of what you will tolerate, at the end of the day you’re the expert and all the liability is on you so I’d want to be ultimately responsible for my decisions not be dictated them..not an easy decision though good luck and explore what else is out there
 
Taking on an NP to supervise should be well compensated and you are ultimately in charge of the decision making. Any place where this is not the case is a huge problem. And if an NP really stinks, you should be able to stop being their supervisor, even if this means the clinic/hospital has to fire them.

It's easy for me to say because I don't supervise any midlevels. But if I was somehow told to take on 4, I would insist on several thousand dollars per month for EACH ONE. It's great that we'll be able to increase community access for psychiatric care, but there's no reason why the clinic/hospital should profit off the NPs while the doctor supervises and takes on all the work/stress/liability and gets paid peanuts.

Why don't our national psychiatric organizations provide some guidance on this. I mean, if a psych NP is bringing in $240K and gets paid $140K, the physician should get 3/4 of that extra $100K, or at least half...the clinic/hospital is getting a great deal if the psychiatist only gets half. I don't get why any psychiatrist is taking on this burden for a few hundred a month. Please have some self respect and understand your value (like everyone in admin and the RNs do).

If a hospital really needs an NP to continue working and they must have a supervisor they will pay to do it, even if reluctantly so.
 
J ROD said:
I mainly like my job and what I do but they also have NP been there for 30+ years in charge of inpatient unit and in admin. She basically calls me at times and bullies me into taking social admits that truly do not meet inpatient criteria. I am over inpatient units as MD but in some weird way she is not over me but is. I refused one time to accept and got called by CEO and told that pt is coming to unit. I really do not care if another MD tells me higher up I have to take the patient. I just do not think a NP should be bullying me to accept patients that are basically social admits. I understand her bosses on her ass. But still......I am the MD.
Click to expand...
Man this sucks. I feel ya. The issue with your organisation is that they try to have it both ways. If they want the NP to act independently then fine, don't put the liability on you by making you the attending physician signing off on it, OR they gotta let you have the final say.

NPs or MDs aside I don't think anyone should be bullying someone else in general, much less bullying a coworker who is working in a "horizontal" (same rank) role.
 
J ROD said:
Well, I get called by medical director who is her age. I basically get reprimanded for talking to her and making her upset. I expressed as MD she is working under my license, I make the medication calls. Director says well, they have say too and basically says we should work it out. I was like hard to work out when they just dc it and say nothing. In meeting she admitted to dc. I was so pissed I about quit right there but I need money to live. So, now she basically works on another floor under him and I do not supervise her anymore as I refused. He said ok and I basically took a less role and money in this deal.

I mainly like my job and what I do but they also have NP been there for 30+ years in charge of inpatient unit and in admin. She basically calls me at times and bullies me into taking social admits that truly do not meet inpatient criteria. I am over inpatient units as MD but in some weird way she is not over me but is. I refused one time to accept and got called by CEO and told that pt is coming to unit. I really do not care if another MD tells me higher up I have to take the patient. I just do not think a NP should be bullying me to accept patients that are basically social admits. I understand her bosses on her ass. But still......I am the MD.
Click to expand...

This sounds like a for-profit institution that is run by NPs. If you're unwilling to walk away, you're helpless. So if you want to stay, you will have to adapt to the culture.

During my job search, I came across many jobs that needed supervision of NPs. If these types of places reached out to me, I always ask for option not to supervise and the option to rescind supervision if I choose to supervise. I will specifically include this in my contract. Places which are inflexible about this are automatically rejected. I'm very direct as I don't like to waste time and being direct brings out the personality of the other person when he or she is under pressure.

One CEO's parting jab was that I may reconsider when I was "more experienced". A year and a half afterwards, I received an e-mail that they were looking for a psychiatrist. I look up his facility and noticed he lost a psychiatrist just after 1 year of recruiting her. I guess he wasn't that experienced when it comes to physician retention.

Another place asked me if I respected NPs after I said I didn't want to supervise. I said I respect them but that doesn't mean I want to supervise them.

I'm very surprised that the CEO would tell you that the patient is coming to the unit. I hope it was under his license and not under your license. Does he tell you what medications to prescribe as well? The owner of the previous practice I worked at would tell me what to bill. That (among other things) was when I knew I had to leave.
 
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I personally have no issue monitoring couple NP when I bill for their work and get the wrvu. However, when they do not listen and go against my wishes on my license that is different. Three would never do it. Two appear to think otherwise.

CEO called mainly bc of COVID and needed the bed. It was a severe autism pt that was getting more agitated on the floor.
 
J ROD said:
my main issue is with NP thinking they can tell MD what to do and my director basically backing them. Probably why they are not able to keep MD. I know of 7 that have left within 4 years. Two recently. Basically every MD except director. since 2016 when he took over.
Click to expand...
NP runs to the boss and complains when you question them about egregious decisions and lying? Sounds like a time-honored nursing 101 tactic.

But, every doctor who chooses to work for an institution, needs to make peace with the fact that they've lowered themselves to employee status for money and whatever perceived psychic benefit. You have professional training and a professional license that grants you the privilege to practice medicine unfettered by laypersons. Your professional opinion is final, and can only be judged by your peers. You earned that privilege through years of schooling, training, and exams.

If you agree to be an employee corporate cog, you have ceded your privilege to unfettered professional judgment and agree to be subject to the corporate world where politics, alliances, and $ trump your MD and license. You are no longer captain of the ship (unless there's a lawsuit and suddenly you are elevated from employee to physician).

The reality is The Man does not care about patients or whether you are practicing medicine properly. As an employee, your role is simply to rent your license (and document just enough to hit coding criteria) so The Man can bill Medicaid/care, while you bear the malpractice risk.

Again, if you want to remain an employee, embrace your role. Start seeing The Man's point of view, which is to make $. What makes more dollars and cents for The Man? Causing friction with fellow cogs (a.k.a. NPs/cost-reduction units) or continuing business as usual? Keeping out social admissions or keeping the unit full with social admissions? Eventually you have to do the mental gymnastics to relieve the cognitive dissonance (i.e., Who am I to judge who needs hospitalization?If someone requests hospitalization, they must need help on some level). Or you quit.
 
J ROD said:
bad deal. Move on if you can. I recently had an issue with one of NP. I was working on meds for sleep on patient. I changed the medication. They dc it without my knowledge. Couple days go by and I think they are getting this medication. I was changing another medication and noticed the sleep medication was not there. Search EPIC and find NP dc it. I ask them about it. Say I do not know, then says I did not do it. I confront them and show it plainly on EPIC.

Some background. I am about 20 years younger, they have about same years psychiatry experience as myself. In my second year as attending. NP was family medicine for 30+ years. From day 1, always had issue with myself as attending likely due to age. NP has been there 4 years before me.

Well, I get called by medical director who is her age. I basically get reprimanded for talking to her and making her upset. I expressed as MD she is working under my license, I make the medication calls. Director says well, they have say too and basically says we should work it out. I was like hard to work out when they just dc it and say nothing. In meeting she admitted to dc. I was so pissed I about quit right there but I need money to live. So, now she basically works on another floor under him and I do not supervise her anymore as I refused. He said ok and I basically took a less role and money in this deal.

I mainly like my job and what I do but they also have NP been there for 30+ years in charge of inpatient unit and in admin. She basically calls me at times and bullies me into taking social admits that truly do not meet inpatient criteria. I am over inpatient units as MD but in some weird way she is not over me but is. I refused one time to accept and got called by CEO and told that pt is coming to unit. I really do not care if another MD tells me higher up I have to take the patient. I just do not think a NP should be bullying me to accept patients that are basically social admits. I understand her bosses on her ass. But still......I am the MD.

Money is good and job is fairly easy. But, I feel like a resident again in many ways.

Just wanting some advice, to vent, and thoughts? It had been bothering me for weeks.....
Click to expand...

I would leave but that's me. There are more important things in life than money, like self respect and boundaries. No one talks to me that way and no one reprimands me for telling an NP what's up when they d/c a med I ordered. And this BS of "they have say too" is just that, BS. They have a say too when they get independent rights, not before. I don't put my license on the line for anyone so if I disagree with their plan of care, it's either going to change or they're going to have to find a new supervising physician.

If, as psychiatrists, we all stopped supervising these NPs, they may get independent rights since no one wants to supervise them, but the good thing about that is that we can track their outcomes for real. Right now, NP outcomes are colored by MD supervision AND assignment of cases with less acuity. If they want to be treated like physicians, lets see them treated like physicians and see how many medical co-morbidities they miss, how many people they kill with their prescribing practices, and how many malpractice cases come their way, completely on their own.
 
Candidate2017 said:
If you agree to be an employee corporate cog, you have ceded your privilege to unfettered professional judgment and agree to be subject to the corporate world where politics, alliances, and $ trump your MD and license. You are no longer captain of the ship (unless there's a lawsuit and suddenly you are elevated from employee to physician).

The reality is The Man does not care about patients or whether you are practicing medicine properly. As an employee, your role is simply to rent your license (and document just enough to hit coding criteria) so The Man can bill Medicaid/care, while you bear the malpractice risk.
Click to expand...
It's fascinating to me how incredibly universally true this has fit the experience of all the doctors I know regardless of specialty, regardless of for-profit or not-for-profit. If there's one thing to give credit to the corporate world for, it's how universally they pursue the $ while minimizing amount of work for themselves.
 
The OP is pretty clearly not happy with their job. They have my blessing to leave. 🙂 There's no good way to actually determine the amount of "liability" in this situation, but if it's literally keeping the OP up at night, the pay isn't nearly good enough.
 
Merovinge said:
It's fascinating to me how incredibly universally true this has fit the experience of all the doctors I know regardless of specialty, regardless of for-profit or not-for-profit. If there's one thing to give credit to the corporate world for, it's how universally they pursue the $ while minimizing amount of work for themselves.
Click to expand...
Well, that's the point of a corporation. To pool large amounts of money from investors to form an entity headed by a few risktakers to embark on a literal voyage to make massive amounts of money. East India Tea Company, Magellan, Columbus etc were among the first to utilize corporations.
 
Candidate2017 said:
Well, that's the point of a corporation. To pool large amounts of money from investors to form an entity headed by a few risktakers to embark on a literal voyage to make massive amounts of money. East India Tea Company, Magellan, Columbus etc were among the first to utilize corporations.
Click to expand...
Those are very different examples. I understand corporations designed to pool money in an attempt to take a voyage ala Tesla, General Motors, Netflix or any other of hundreds/thousands of examples. Health care delivery corporations are very different, they appear to do as much rent seeking as possible with the overwhelming majority have no interest in disrupting any status quo or having innovation. Their goals seem to be to take as little risk as possible while maximizing the skimming from the work of health care professions and government/insurance reimbursement. Really do not see the correlation to East India Company.
 
Merovinge said:
Those are very different examples. I understand corporations designed to pool money in an attempt to take a voyage ala Tesla, General Motors, Netflix or any other of hundreds/thousands of examples. Health care delivery corporations are very different, they appear to do as much rent seeking as possible with the overwhelming majority have no interest in disrupting any status quo or having innovation. Their goals seem to be to take as little risk as possible while maximizing the skimming from the work of health care professions and government/insurance reimbursement. Really do not see the correlation to East India Company.
Click to expand...

East India Company was mainly about exploiting a royally granted monopoly and threatening local governments with armed force if they did not grant trade concessions early on and then later mainly by extracting tax revenue out of tens of millions of people. Very much not what we think of when we imagine modern business entities.
 
Oh, gosh…. I wouldn’t do that job for any salary. Was there a signing bonus? If so you would need to pay it back if you haven’t been there long enough.
 
hebel said:
Bad job in my opinion. Your salary would be fair for just the patients you see on your own.

Even ethically, I don't think these kind of practices should exist.
Click to expand...
In my state, psychiatrists supervise numerous midlevels who can be as far as several hours away. They don't give a Smurf.
 
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