job prospects in Texas

[justordinary]

I've been in NY (near NYC) for the past several years and recently have been thinking about moving to Texas (leaning towards Dallas, but open to other cities too including Houston, Austin, etc).
I was wondering if anyone who has experience practicing psychiatry in Texas can give me any good insight.
Reasons for thinking about moving out of NY include:
1) Cost of living is wayyy too high (property tax, state income tax, real estate price, etc) compared to compensation. Psychiatrists really don't get paid that much around this area and it's getting harder and harder to afford a good living while paying off mortgage, student loans, etc
2) NPs have been taking over the field of psychiatry... just at my institution alone, they closed down all job openings for MDs and converted them to NP positions.
3) it's getting harder and harder to open private practice... big hospitals are pretty much taking over and restrictive covenant is getting more and more ruthless
4) maybe this is just the institution that I work at..or maybe it's NYC area/Northeast in general... but I really feel like I'm disposable. I'm just there to produce RVU for the hospital and they are ready to push me out as soon as they can find someone cheaper to replace me with. I find myself wondering, "why did I go to medical school and do residency?"
5) I don't like the Northeast winter....
6) NYC had its charms... but is it worth it with high cost of living around here? After COVID, city really does not have much to offer... of course, it may recover, but for now it is certainly not what it used to be...

I have never lived in Texas but I've heard nothing but positive things from people who lived there. However, these people were physicians in other specialties and not psychiatry. It would be great to have any advice/insight from anyone who has experience living/practicing psychiatry in Texas, and in metropolis region if possible. Thanks in advance!

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[TexasPhysician]

I enjoy Texas, but I have a lot of family here. Job prospects are likely better than the NE, but likely not as good as the Midwest. Midlevel encroachment are major issues everywhere. In my city alone, there are large NP private clinics focused on mental health. Some MD sells their license and isn’t on site. I eventually catch them on something and report the MD to the medical board. Downside is that it’s like whack a mole. 1 MD leaves and another signs up for a future board violation. Very frustrating.

The winters are much better, but outsiders struggle with the humidity in eastern half of Texas. I was born into it, so I don’t notice as much. I’m accustomed to walking outside in the summer and immediately start sweating as the door opens.

I don’t think Texas is a bad place to go, but I wouldn’t move here just to escape somewhere else. Maybe do some locums work and find somewhere that you really enjoy.

 

[Sushirolls]

Other income tax free states are WA, and Alaska.
Alaska pays you to live in the state and has no sales tax.
Washington has a sales tax.
Both of those states are geographically diverse and have different weather climates. For instance Spokane WA is a 4 seasons kind of place but really no summer humidity.
Western WA and SE Alaska are 8 months of drizzle with rare snow.

Something else to consider if Texas was selected because of income tax status.

 

[J ROD]

Just go to Florida like everyone else........

 

[justordinary]

Just go to Florida like everyone else........

what would be a major advantage of going to FL instead of Texas?

 

[justordinary]

Other income tax free states are WA, and Alaska.
Alaska pays you to live in the state and has no sales tax.
Washington has a sales tax.
Both of those states are geographically diverse and have different weather climates. For instance Spokane WA is a 4 seasons kind of place but really no summer humidity.
Western WA and SE Alaska are 8 months of drizzle with rare snow.

Something else to consider if Texas was selected because of income tax status.

income tax is one factor but some crucial other factors include weather... which rules out Washington and Alaska... thanks for the insight though. It appears like there is mass exodus of people from California to Texas recently, I dunno how that would change things in the future..

 

[NickNaylor]

I was born and raised in Texas and am currently practicing in Dallas.

COL is great in Texas, and no state income tax is awesome. Dallas specifically has plenty of "culture" if that's something you care about. No, it's not going to be the same as a metropolitan area like NYC, but there is still plenty to do. The downtown area is growing like crazy and the dense areas remind me a lot of my time in Chicago - lots of great restaurants, relatively easily walkable, etc. Probably the biggest lifestyle change will be needing to have a car - mass transit in Dallas is hot garbage unless everywhere you need to go is pretty centrally located. I work at an academic hospital but several of my residency classmates have gone into private practice. There are plenty of opportunities to go that route if that's what you'd prefer. For those that started or joined a private practice, I haven't heard of any of them having trouble with getting their practices started.

I'd be happy to answer any questions you might have though I'm not quite sure what kind of information/perspectives you'd be interested in. Texas generally and Dallas specifically is a great place to raise a family if you're at that phase of life. I love it here.

 

[justordinary]

I was born and raised in Texas and am currently practicing in Dallas.

COL is great in Texas, and no state income tax is awesome. Dallas specifically has plenty of "culture" if that's something you care about. No, it's not going to be the same as a metropolitan area like NYC, but there is still plenty to do. The downtown area is growing like crazy and the dense areas remind me a lot of my time in Chicago - lots of great restaurants, relatively easily walkable, etc. Probably the biggest lifestyle change will be needing to have a car - mass transit in Dallas is hot garbage unless everywhere you need to go is pretty centrally located. I work at an academic hospital but several of my residency classmates have gone into private practice. There are plenty of opportunities to go that route if that's what you'd prefer. For those that started or joined a private practice, I haven't heard of any of them having trouble with getting their practices started.

I'd be happy to answer any questions you might have though I'm not quite sure what kind of information/perspectives you'd be interested in. Texas generally and Dallas specifically is a great place to raise a family if you're at that phase of life. I love it here.

There are few aspects of my job (academia) that I'm unhappy with, and I just wasn't sure if this is my institution or psychiatry in general...
1) my job is 0.9 FTE RVU based... which means that for 40 hour work week, I'm given 4 hours to do "other things expected from academic physician" which include attending Grand rounds, various department meetings, teaching sessions, research, administrative stuff and etc... and my institution is pretty brutal with RVU - if you can't produce at least 50th percentile then you are pushed out immediately. In all honesty, 4 hours isn't anywhere close to what a person needs to produce any meaningful research publications, engage in teaching etc. that's barely enough to attend weekly meetings and do some paperwork/write notes/deal with insurance/etc. And that 4 hours isn't actually even built and protected in your schedule, it's more like you have to squeeze them in on your own, otherwise they just schedule patients. But if you don't meet this "academic expectation" of being engaged in research, your position is shaky and you don't get promoted. This means you just have to sacrifice weekends and put in after-hours to engage in research. I don't like working for free.
2) NPs can practice independently in NY. They can open their PP, work for big hospitals (they are called "faculty member" at my institution), etc. At my institution, some NPs are even allowed to teach residents. I don't see this trend changing anytime soon, and I don't think my institution is interested in changing this because it's cheaper to hire NPs.
3) It's pretty much near impossible to open PP near where I live with so much regulations... Not one single person from my residency class opened PP, not one single person year above my residency class opened PP, not one single person year below my residency class opened PP.
4) Restrictive covenant.. I'm not sure how strongly this is imposed in Texas
5) there is tort reform in Texas, none in NY

Aside from the job, I guess I will miss the culture and arts that NYC can offer but with high taxes and COL (which I predict is only going to go up after COVID), I'm not sure if it's worth it to live near NYC. I've never visited Dallas but I would love to in the future to see what it's like. I don't mind driving as I'm used to it. The only thing I'm nervous about is
1) I don't have any connections to Dallas so how would I go about in finding a job...? go through a recruiter? internet search?
2) don't know anyone in Texas so it will be an adjustment, but that's something I've gotta face.

 

[Sushirolls]

Seems like your are drowning in Big Box Shop Bureaucracy.

 

[justordinary]

Seems like your are drowning in Big Box Shop Bureaucracy.

exactly...thought academia might be less big-box shop but i guess not... Feel like I need to get out before I actually drown...

 

[dl2dp2]

3) It's pretty much near impossible to open PP near where I live with so much regulations... Not one single person from my residency class opened PP, not one single person year above my residency class opened PP, not one single person year below my residency class opened PP.

? where is this in NY? Parts of NYC market is one of the top-performing, if not *the* top-performing market for psychiatry PP. If one wants to make 1M+ in psychiatry one should probably stay in NY or move to a very small number of other places (not sure Dallas is in this category. Houston probably is). The difficulty with PP in NYC area also has nothing to do with regulation.

Nothing wrong with moving (I did), but do it for the right reasons.

 

[justordinary]

? where is this in NY? Parts of NYC market is one of the top-performing, if not *the* top-performing market for psychiatry PP. If one wants to make 1M+ in psychiatry one should probably stay in NY or move to a very small number of other places (not sure Dallas is in this category. Houston probably is). The difficulty with PP in NYC area also has nothing to do with regulation.

Nothing wrong with moving (I did), but do it for the right reasons.

I live in suburbs of NYC. Not sure if there is one reason for none of the younger psychiatrists I know are trying to open up PP here, I believe it's a combination of many different factors... the general atmosphere when I was a resident few years back was we were not taught anything about PP nor was it encouraged (actually it was even kind of discouraged, and we were all encouraged to go into "public sector" psychiatry -whatever that means, but that was probably just the institution I trained at. Might have changed now, thought not certain). I don't have to make millions doing PP but it would be nice to feel that is an option - not sure if Texas is PP friendly or more big-institution friendly, or about the same.

 

[dl2dp2]

I live in suburbs of NYC. Not sure if there is one reason for none of the younger psychiatrists I know are trying to open up PP here, I believe it's a combination of many different factors... the general atmosphere when I was a resident few years back was we were not taught anything about PP nor was it encouraged (actually it was even kind of discouraged, picturing them as money-hungry people, and we were all encouraged to go into "public sector" psychiatry, but that was probably just the institution I trained at. Might have changed now, thought not certain). I don't have to make millions doing PP but it would be nice to feel that is an option - not sure if Texas is PP friendly or more big-institution friendly, or about the same.

Do you have a restrictive covenant?

 

[calvnandhobbs68]

I live in suburbs of NYC. Not sure if there is one reason for none of the younger psychiatrists I know are trying to open up PP here, I believe it's a combination of many different factors... the general atmosphere when I was a resident few years back was we were not taught anything about PP nor was it encouraged (actually it was even kind of discouraged, picturing them as money-hungry people, and we were all encouraged to go into "public sector" psychiatry, but that was probably just the institution I trained at. Might have changed now, thought not certain). I don't have to make millions doing PP but it would be nice to feel that is an option - not sure if Texas is PP friendly or more big-institution friendly, or about the same.

You mentioned regulations but what additional regulations does new york state have for opening a psychiatry private practice?

 

[dl2dp2]

You mentioned regulations but what additional regulations does new york state have for opening a psychiatry private practice?

The answer is none. He/she is not informed because he/she hasn't actually started a practice. Again, this is why as I said in a different thread, the answer to all these questions (i.e. should I move to Texas because I hate my academic day job?) is to start your own practice. Right now. If you can.

There are "additional" annoyances in NYS. e.g. due to covid and other various things, the timeframe of getting a PLLC approved is now 6 months plus and cost > $1000 if you count the stupid publications requirement. But this doesn't stop anyone from starting a sole proprietorship en-route, or if you are baller, start your LLC in Delaware and franchise in NY.

 

[TexasPhysician]

? where is this in NY? Parts of NYC market is one of the top-performing, if not *the* top-performing market for psychiatry PP. If one wants to make 1M+ in psychiatry one should probably stay in NY or move to a very small number of other places (not sure Dallas is in this category. Houston probably is). The difficulty with PP in NYC area also has nothing to do with regulation.

Nothing wrong with moving (I did), but do it for the right reasons.

Friend in NYC in pp has considered moving to TX. This friend bills at $800/hr in NYC. Houston and Dallas market analysis would put this friend around $300/hr in pp. These are cash numbers pre-overhead assuming enough patients to fill your practice. Obviously numbers will vary from person to person.

 

[dl2dp2]

Friend in NYC in pp has considered moving to TX. This friend bills at $800/hr in NYC. Houston and Dallas market analysis would put this friend around $300/hr in pp. These are cash numbers pre-overhead assuming enough patients to fill your practice. Obviously numbers will vary from person to person.

Is that really true tho? I feel like people underestimate the number of wealthy people in Texas. Obviously, I haven't investigated this but I feel like you can fill a practice in Houston on $6-800 an hour. Other service sector jobs (corporate lawyer, etc) rates are only about at most 30% lower.

If what you say is really true then I suspect this friend would resist moving to TX.... right?

 

[Stagg737]

There are few aspects of my job (academia) that I'm unhappy with, and I just wasn't sure if this is my institution or psychiatry in general...
1) my job is 0.9 FTE RVU based... which means that for 40 hour work week, I'm given 4 hours to do "other things expected from academic physician" which include attending Grand rounds, various department meetings, teaching sessions, research, administrative stuff and etc... and my institution is pretty brutal with RVU - if you can't produce at least 50th percentile then you are pushed out immediately. In all honesty, 4 hours isn't anywhere close to what a person needs to produce any meaningful research publications, engage in teaching etc. that's barely enough to attend weekly meetings and do some paperwork/write notes/deal with insurance/etc. And that 4 hours isn't actually even built and protected in your schedule, it's more like you have to squeeze them in on your own, otherwise they just schedule patients. But if you don't meet this "academic expectation" of being engaged in research, your position is shaky and you don't get promoted. This means you just have to sacrifice weekends and put in after-hours to engage in research. I don't like working for free.
2) NPs can practice independently in NY. They can open their PP, work for big hospitals (they are called "faculty member" at my institution), etc. At my institution, some NPs are even allowed to teach residents. I don't see this trend changing anytime soon, and I don't think my institution is interested in changing this because it's cheaper to hire NPs.
3) It's pretty much near impossible to open PP near where I live with so much regulations... Not one single person from my residency class opened PP, not one single person year above my residency class opened PP, not one single person year below my residency class opened PP.
4) Restrictive covenant.. I'm not sure how strongly this is imposed in Texas
5) there is tort reform in Texas, none in NY

Aside from the job, I guess I will miss the culture and arts that NYC can offer but with high taxes and COL (which I predict is only going to go up after COVID), I'm not sure if it's worth it to live near NYC. I've never visited Dallas but I would love to in the future to see what it's like. I don't mind driving as I'm used to it. The only thing I'm nervous about is
1) I don't have any connections to Dallas so how would I go about in finding a job...? go through a recruiter? internet search?
2) don't know anyone in Texas so it will be an adjustment, but that's something I've gotta face.

Your first point sounds awful. 4 hours of admin/teaching/research time that isn't even protected? How can your program even call itself academic? That's awful.

To the second point, NPs should NOT be teaching residents and in addition to be unethical it's technically illegal as states with FPA for NPs have gained it by arguing they practice nursing and not medicine, and therefore technically cannot train physicians as they don't practice medicine (obviously BS, but yay politics).

I have extended (non-medical) family in Dallas and it seems like a pretty solid area. I've also visited Houston a few times and while also a lot of fun/nice, the humidity was terrible.

Do you have a restrictive covenant?

There are few aspects of my job (academia) that I'm unhappy with, and I just wasn't sure if this is my institution or psychiatry in general...

4) Restrictive covenant.. I'm not sure how strongly this is imposed in Texas

 

[dl2dp2]

4) Restrictive covenant.. I'm not sure how strongly this is imposed in Texas

Restrictive covenant is uncommon in NY for facilities-based jobs in my experience, except in tier 1 academic practices, as a lot of them are associated with either the state/Medicaid, or some other public/private carve-out, and hence by their very nature are lower than market salaried. In fact, my experience has been they are getting LESS common as attrition of jobs with restrictive covenant is increasing for obvious reasons, and affiliates of tier 1 (i.e. not their flagship) are getting rid of restrictive covenents in aim to retain quality clinicians who have their own side practices. If this is the issue maybe the answer is switch job in NY instead of going directly to TX--of course the immediate issue is that the academic role might have a higher base salary. I suspect tier 1 academic jobs in TX also have restrictive covenant so you'd have to swap out to a job that's not directly comparable. It's an interesting issue -- more frequently associated with certain kinds of careers (i.e. academic) that require a level of prestige and therefore have poorer supply/demand.

 

[justordinary]

I guess options are:
1) open PP in NY area. All the other things that suck about being in Northeast would still be there but there is more freedom and higher potential earning in NY compared to elsewhere.
2) look elsewhere including Texas. Compensation for PP might not be as high but there are other good things that come with escaping Northeast.

I know grass is not always greener on the other side, but I guess you wouldn't know until you've been on the other side. I guess I'm just sad that psychiatrists are now just cog in a wheel in big bureaucracy if you work for a big institution....

 

[justordinary]

Restrictive covenant is uncommon in NY for facilities-based jobs in my experience, except in tier 1 academic practices. In fact, my experience has been they are getting LESS common as attrition of jobs with restrictive covenant is increasing for obvious reasons, and affiliates of tier 1 (i.e. not their flagship) are getting rid of restrictive covenents. If this is the issue maybe the answer is switch job in NY instead of going directly to TX. I suspect tier 1 academic jobs in TX also have restrictive covenant. This issue is more frequently associated with prestige and supply/demand.

could you explain more about this phenomenon?

 

[dl2dp2]

could you explain more about this phenomenon?

Non-prestigious nonprofits bid for a contract from the state to take care of a group of Medicaid patients. The lowest bidder gets the contract, which says the psychiatrist hired will get paid $200k. The agreement means the salary cannot be negotiated on hire. However, nowhere in the agreement says you can't have a side gig somewhere else. So the implicit understanding is that this is a chill job with lots of no-shows, and this staff psychiatrist maintains a side gig.

Prestigious academic medical center starts a "faculty practice" that either charge cash or has private agreements with commercial insurance that bills above market rates. The faculty psychiatrist gets paid $250k but are restricted from any side gig, because the side gig would be a direct competition of the role of the faculty practice, in which each hour of faculty work has a sizable profit margin for the facility. Hence, restrictive covenant is the norm.

At the end of the day, total comp of first person often >>> second person. The second person has certain career paths open (i.e. senior leadership, research, education, etc). Nevertheless, if you ask around for a job that has no restrictive covenant, you'll be taking a "pay cut". This prevents you psychologically from jumping ship. But you are overall getting the trade-offs: the total income/lifestyle ceiling is higher in NY, and typically involves taking on risks--whereas, the overall quality of the average job/take-home compensation is probably higher in TX. But you know that already: this is basically true for every job ever. People go to NY to take risks for higher ceiling pretty much since NY existed. Right?

 

[justordinary]

Non-prestigious nonprofits bid for a contract from the state to take care of a group of Medicaid patients. The lowest bidder gets the contract, which says the psychiatrist hired will get paid $200k. The agreement means the salary cannot be negotiated on hire. However, nowhere in the agreement says you can't have a side gig somewhere else. So the implicit understanding is that this is a chill job with lots of no-shows, and this staff psychiatrist maintains a side gig.

Prestigious academic medical center starts a "faculty practice" that either charge cash or has private agreements with commercial insurance that bills above market rates. The faculty psychiatrist gets paid $250k but are restricted from any side gig, because the side gig would be a direct competition of the role of the faculty practice, in which each hour of faculty work has a sizable profit margin for the facility. Hence, restrictive covenant is the norm.

At the end of the day, total comp of first person often >>> second person. The second person has certain career paths open (i.e. senior leadership, research, education, etc). Nevertheless, if you ask around for a job that has no restrictive covenant, you'll be taking a "pay cut". This prevents you psychologically from jumping ship. But you are overall getting the trade-offs: the total income/lifestyle ceiling is higher in NY, and typically involves taking on risks--whereas, the overall quality of the average job/take-home compensation is probably higher in TX. But you know that already: this is basically true for every job ever. People go to NY to take risks for higher ceiling pretty much since NY existed. Right?

thanks for the insight... this was very informative.

 

[psychacad]

There are good gigs in NY if you know where to look. It just seems you work in a bad place. Disagree about psychiatrists becoming cogwheels. You can work part time in NYC for 200k on a per diem basis. Add a bit of PP and you're all set, and you're still below full time schedule. How many other specialties have this kind of flexibility?

Salaried positions in general are not the best unless in select places that really care about quality of patient care and well being of doctors. These you won't find with recruiters.

 

[TexasPhysician]

Is that really true tho? I feel like people underestimate the number of wealthy people in Texas. Obviously, I haven't investigated this but I feel like you can fill a practice in Houston on $6-800 an hour. Other service sector jobs (corporate lawyer, etc) rates are only about at most 30% lower.

If what you say is really true then I suspect this friend would resist moving to TX.... right?

Friend is still considering it for personal family reasons. The numbers are accurate. I’m in the TX markets to verify that. Friend is in NY to verify there. Maybe there is a niche in TX that could hit much higher numbers, but it won’t be easy at all.

 

[justordinary]

There are good gigs in NY if you know where to look. It just seems you work in a bad place. Disagree about psychiatrists becoming cogwheels. You can work part time in NYC for 200k on a per diem basis. Add a bit of PP and you're all set, and you're still below full time schedule. How many other specialties have this kind of flexibility?

Salaried positions in general are not the best unless in select places that really care about quality of patient care and well being of doctors. These you won't find with recruiters.

I guess I'm having a hard time finding jobs without the help of internet search and recruiters... These good jobs seem more hidden, at least from my experience.

Friend in NYC in pp has considered moving to TX. This friend bills at $800/hr in NYC. Houston and Dallas market analysis would put this friend around $300/hr in pp. These are cash numbers pre-overhead assuming enough patients to fill your practice. Obviously numbers will vary from person to person.

wouldn't $800/hr considered a "niche" even in NYC?

 

[Stagg737]

Restrictive covenant is uncommon in NY for facilities-based jobs in my experience, except in tier 1 academic practices, as a lot of them are associated with either the state/Medicaid, or some other public/private carve-out, and hence by their very nature are lower than market salaried. In fact, my experience has been they are getting LESS common as attrition of jobs with restrictive covenant is increasing for obvious reasons, and affiliates of tier 1 (i.e. not their flagship) are getting rid of restrictive covenents in aim to retain quality clinicians who have their own side practices. If this is the issue maybe the answer is switch job in NY instead of going directly to TX--of course the immediate issue is that the academic role might have a higher base salary. I suspect tier 1 academic jobs in TX also have restrictive covenant so you'd have to swap out to a job that's not directly comparable. It's an interesting issue -- more frequently associated with certain kinds of careers (i.e. academic) that require a level of prestige and therefore have poorer supply/demand.

It is interesting, was just pointing out OP's current position does have a restrictive covenant, but from their description it sounds like there are many other issues there as well.

 

[psychacad]

I guess I'm having a hard time finding jobs without the help of internet search and recruiters... These good jobs seem more hidden, at least from my experience.

It does need a bit of perseveration and patience. I would recommend to pick up the phone, send emails and ask for potential positions. Also have an idea what would be your ideal job and go from there. You can do this for any geographical region you envision working in. CA pays significantly more than the NE; I know people complain about taxes, COL...etc but still. Once you get to know a certain system you will also hear about even more positions. Make connections outside your residency circle. Searching for jobs online is probably the worst way to find a suitable job. Of course it doesn't hurt to be connected to recruiters but the chance of find a decent position that way is quite small.

Your gig sounds horrible. Let them get the RN's they want and get out of that hell hole.

 

[AD04]

I really don't see the allure of NYC area and I grew up there. Crowded. High taxes. High cost of living. Nasty winter. Quite a few of my high school classmates and childhood friends are working in the financial industry (investment banking / hedge fund / private equity) and a few in big law so they are there as the jobs are there.

But as a physician, I have free reign of where I will live as I can get a job pretty much anywhere. And I took advantage of that. I left the area and never went back. Not only are my taxes and cost of living lower, I wouldn't be surprised if I outearn my former classmates and childhood friends either. None of this was planned. I just went to where the opportunities were and jumped ship if there is something better (e.g. more growth, more compensation, more honesty).

Go out and explore and make mistakes and learn about the business aspect of medicine. And if you don't like your situation, pivot to greener pastures. You don't like NYC (I don't blame you) and your job sucks. So if you're really thinking of moving to TX, do it. At the very least you'll learn something new and you may very well find a better position.

 

[psychacad]

I really don't see the allure of NYC area and I grew up there. Crowded. High taxes. High cost of living. Nasty winter. Quite a few of my high school classmates and childhood friends are working in the financial industry (investment banking / hedge fund / private equity) and a few in big law so they are there as the jobs are there.

But as a physician, I have free reign of where I will live as I can get a job pretty much anywhere. And I took advantage of that. I left the area and never went back. Not only are my taxes and cost of living lower, I wouldn't be surprised if I outearn my former classmates and childhood friends either. None of this was planned. I just went to where the opportunities were and jumped ship if there is something better (e.g. more growth, more compensation, more honesty).

Go out and explore and make mistakes and learn about the business aspect of medicine. And if you don't like your situation, pivot to greener pastures. You don't like NYC (I don't blame you) and your job sucks. So if you're really thinking of moving to TX, do it. At the very least you'll learn something new and you may very well find a better position.

There are very few places in the world though though where you can get out of your apartment and the world is literally at your fingertip. There is a trade off for the smaller apartment. The extra local taxes imo compensate for a need for a car. Living in NYC suburbs and Manhattan is a completely different experience. I agree, the former is probably not worth it.

 

[Merovinge]

There are very few places in the world though though where you can get out of your apartment and the world is literally at your fingertip. There is a trade off for the smaller apartment. The extra local taxes imo compensate for a need for a car. Living in NYC suburbs and Manhattan is a completely different experience. I agree, the former is probably not worth it.

I agree, definitely different strokes for different folks but if one cannot even imagine why people like to live in the heart of world class cities there is a real lack of experience or ability to take the perspective of others. There's a reason why people who are independently wealthy and do not even work choose to live in LA, NYC, Paris, Singapore, etc.

I personally cannot imagine living on a 50 acre plot of land that cost less then the lint in my pocket 3 hours from the nearest airport but I definitely can understand the appeal to some.

 

[justordinary]

NYC definitely does have its appeals, but i've found that their salaried positions actually pay less than suburbia of NYC. I guess if you own PP in NYC then there is definitely more potential to charge more for an hour as NYC does have higher number of very wealthy people compared to suburbia. In terms of living in the suburbia of NYC (NJ and near vicinity NY area), I'm not sure if that is necessarily better than living in other area of the country... I guess you do get access to the city of you want to make the trip, but it's definitely different from being able to walk out of your apartment in NYC and having access to this cosmopolitan culture.

Does anyone have any good insight into how different cities would compare in Texas? ie: Austin vs Dallas vs Houston etc.
If I were really to move, any suggestions on how to hunt for jobs?

 

[Sushirolls]

Go line up an interview for a Big Box shop. Take like a 1-2 week vacation during that time. Rent a car, and drive around the state. Go explore. Get a feel for things.

I've posted a variant of this before:
DON'T use a head hunter.
DON't use locums.

DO research this yourself. Google is your reconnaissance friend.
1) Think about what jobs/work you might be more interested in and those you might be less interested in
2) Figure out the geography you want to live in.
3) Search Physician Jobs in the PracticeLink Job Bank will help get you started for a local geography
4) Once you think you have an area of interest, dig deeper

-google the hospitals
-google the psychiatric units. Attached to hospitals and free standing.
-google the addiction detox units. The residential programs
-The community mental health centers
-google terms of psychiatrist or psychiatry near "XYZ" and read the websites in that area
-Look up the methadone clinic locations
-An alternative to google is the psychologytoday website, use this to cross reference the lists you build.
-Look for the closest eating disorder clinic
-Use g maps to see what the drive time radius is to these places.

Once you get a feel for an area, start calling the entities of interest - even if there isn't a job posting - and find out if there is a need for a Psychiatrist.

 

[justordinary]

How is job market in Miami area? It looks like everyone from Northeast are relocating to Miami, FL...

 

[Marasmus1]

How is job market in Miami area? It looks like everyone from Northeast are relocating to Miami, FL...

I have been looking for Jobs recently in Florida. The average compensation is 300k ( In Florida, would never accept anything less than that). No state and local income tax mean you may save extra 3-4 k a month. However, I have to say that the job market is saturated with for profit hospitals where a lot of shady stuff is going on. I am planning to start with inpatient guaranteed compensation in a non profit setting with part time PP with a goal to switch to full time PP in 5 years.

 

[justordinary]

I have been looking for Jobs recently in Florida. The average compensation is 300k ( In Florida, would never accept anything less than that). No state and local income tax mean you may save extra 3-4 k a month. However, I have to say that the job market is saturated with for profit hospitals where a lot of shady stuff is going on. I am planning to start with inpatient guaranteed compensation in a non profit setting with part time PP with a goal to switch to full time PP in 5 years.

Could you plz explain on what you mean by shady for-profit hospitals? Does this mean VA or academic centers are safer....?

 

[Sushirolls]

It means they will view you as a technician who simply needs to say yes. Yes to every admission. Yes to every volume increase for your census coverage and yes to whatever call terms they dictate and yes to whatever compensation they throw at you. It will all be about volume, volume, volume.

Your signature on notes is nothing more than an FDA label in food packaging plant ***[whir of conveyor belt sound cues in background] ...Stamp... stamp... stamp... stamp...***

 

[justordinary]

It means they will view you as a technician who simply needs to say yes. Yes to every admission. Yes to every volume increase for your census coverage and yes to whatever call terms they dictate and yes to whatever compensation they throw at you. It will all be about volume, volume, volume.

Your signature on notes is nothing more than an FDA label in food packaging plant ***[whir of conveyor belt sound cues in background] ...Stamp... stamp... stamp... stamp...***

Is this phenomenon unique to Florida though? I feel that this is happening to Northeast as well... Unless Florida for-profit is exponentially worse you mean

 

[Marasmus1]

Could you plz explain on what you mean by shady for-profit hospitals? Does this mean VA or academic centers are safer....?

Something like this

Administrator : I want this patient out. Insurance declined further inpatient stay. We have patients waiting for admission.
Clinician : But the patient is significantly depressed with very poor support system. Has multiple recent suicide attempts. He definitely needs more time for treatment and a safer discharge plan
Administrator : Well, are you willing to pay the patients bill ?
Clinician : Hih? No... I mean... All I am trying to say is patient is not clinically ready for discharge
Administrator : Somebody gotta pay the bill. No money no honey. This is not a charity,

 

[justordinary]

Something like this

Administrator : I want this patient out. Insurance declined further inpatient stay. We have patients waiting for admission.
Clinician : But the patient is significantly depressed with very poor support system. Has multiple recent suicide attempts. He definitely needs more time for treatment and a safer discharge plan
Administrator : Well, are you willing to pay the patients bill ?
Clinician : Hih? No... I mean... All I am trying to say is patient is not clinically ready for discharge
Administrator : Somebody gotta pay the bill. No money no honey. This is not a charity,

Ahh yes... Unfortunately im all too familiar with nasty admins who love telling doctors what to do, and when **** happens, it's all doctor's fault... I guess there is no way of avoiding these shady admin no matter where you go.... Is anywhere safe??

 

[Candidate2017]

I guess options are:
1) open PP in NY area. All the other things that suck about being in Northeast would still be there but there is more freedom and higher potential earning in NY compared to elsewhere.
2) look elsewhere including Texas. Compensation for PP might not be as high but there are other good things that come with escaping Northeast.

I know grass is not always greener on the other side, but I guess you wouldn't know until you've been on the other side. I guess I'm just sad that psychiatrists are now just cog in a wheel in big bureaucracy if you work for a big institution....

Manhattan (not NYC or suburbs of NYC) is arguably the mecca of PP psychiatry and therapy. Psychiatry is the opposite of other specialties, because the denser the number of psychiatrists, the easier it is to open a practice.

The point of being a professional with a full license is that we are granted the privilege to ply our trade independently and practice independent professional judgment. When you willingly trade that hard-won privilege for the perceived comfort of being an employee, then of course you are going to treated like any employee cog.

It also makes zero sense to take a hospital psychiatry job in some high COL NYC burb paying the same as Texas or elsewhere, with none of the financial/professional/lifestyle advantages of a Manhattan PP.

 

[justordinary]

Manhattan (not NYC or suburbs of NYC) is arguably the mecca of PP psychiatry and therapy. Psychiatry is the opposite of other specialties, because the denser the number of psychiatrists, the easier it is to open a practice.

The point of being a professional with a full license is that we are granted the privilege to ply our trade independently and practice independent professional judgment. When you willingly trade that hard-won privilege for the perceived comfort of being an employee, then of course you are going to treated like any employee cog.

It also makes zero sense to take a hospital psychiatry job in some high COL NYC burb paying the same as Texas or elsewhere, with none of the financial/professional/lifestyle advantages of a Manhattan PP.

Appreciate your input. I still do not think that it is right and expected for an employed physician to be treated as a cog in a wheel. Liability that comes with being a physician is so much greater compared to other trades. I have no experience with Manhattan market but it might be worth exploring...

 

[comp1]

The job pro's and con's are in no way specific to Texas or NYC.

 

[Bartelby]

Psychiatry is the opposite of other specialties, because the denser the number of psychiatrists, the easier it is to open a practice.

Interesting, I have never heard that before. What makes it easier to practice in a market with more psychiatrist "competition?"

 

[Candidate2017]

Interesting, I have never heard that before. What makes it easier to practice in a market with more psychiatrist "competition?"

An area like Manhattan has tons of PP psychiatrists because there are lots of high functioning patients willing and able to pay cash for longer and more frequent psychiatry visits... hour long visits q1-2 weeks etc. This allows psychiatrists to completely fill their schedule with a small panel. Since psychiatrists are completely filled with a small panel, there are actually not enough psychiatrists in Manhattan, despite the area being dense with psychiatrists. Whereas an insurance psychiatrist in a suburb of Texas may need a panel of 400-600 patients to adequately fill, in addition to competing with NPs willing to hand out benzos and stimulants for a $25 copay.

Start up costs are low. No EMR, billing company, or secretary needed. Lots of offices in psychiatric suites available to sublease by the hour, day, or month at surprisingly cheap rates. No need to commit to a lease when starting a practice. Office space is widely available because the more psychiatrists are paid, the less they work.

 

[NickNaylor]

An area like Manhattan has tons of PP psychiatrists because there are lots of high functioning patients willing and able to pay cash for longer and more frequent psychiatry visits... hour long visits q1-2 weeks etc. This allows psychiatrists to completely fill their schedule with a small panel. Since psychiatrists are completely filled with a small panel, there are actually not enough psychiatrists in Manhattan, despite the area being dense with psychiatrists. Whereas an insurance psychiatrist in a suburb of Texas may need a panel of 400-600 patients to adequately fill, in addition to competing with NPs willing to hand out benzos and stimulants for a $25 copay.

Start up costs are low. No EMR, billing company, or secretary needed. Lots of offices in psychiatric suites available to sublease by the hour, day, or month at surprisingly cheap rates. No need to commit to a lease when starting a practice. Office space is widely available because the more psychiatrists are paid, the less they work.

This kind of practice exists in Texas suburbs, though, and it doesn’t seem like people in my area have any trouble building this kind of practice if they want to...

 

[Cath Up]

Something like this

Administrator : I want this patient out. Insurance declined further inpatient stay. We have patients waiting for admission.
Clinician : But the patient is significantly depressed with very poor support system. Has multiple recent suicide attempts. He definitely needs more time for treatment and a safer discharge plan
Administrator : Well, are you willing to pay the patients bill ?
Clinician : Hih? No... I mean... All I am trying to say is patient is not clinically ready for discharge
Administrator : Somebody gotta pay the bill. No money no honey. This is not a charity,

How does an ethical psychiatrist respond to this?

 

[dl2dp2]

This kind of practice exists in Texas suburbs, though, and it doesn’t seem like people in my area have any trouble building this kind of practice if they want to...

Right. As I said above, people overestimate how unique Manhattan is in this regard. I would say at least a dozen locations in the country can support this style of practice. The ceiling might be highest in Manhattan (though even that is questionable) but IMO that's just a matter of degree, not a qualitative difference.

How does an ethical psychiatrist respond to this?

This very rarely happens in real life. Admins are not interested in individual cases. Typically they give you a summary statistics of your overall length of stay and put some performance measure incentive on it.

If an admin is interfering with specific cases when you are the attending of record, that's a problem and can be reflected to his/her leadership team. They might "help you troubleshoot ways to get patients discharged most efficiently", but nobody would be willing to take on these liabilities.

 

[justordinary]

An area like Manhattan has tons of PP psychiatrists because there are lots of high functioning patients willing and able to pay cash for longer and more frequent psychiatry visits... hour long visits q1-2 weeks etc. This allows psychiatrists to completely fill their schedule with a small panel. Since psychiatrists are completely filled with a small panel, there are actually not enough psychiatrists in Manhattan, despite the area being dense with psychiatrists. Whereas an insurance psychiatrist in a suburb of Texas may need a panel of 400-600 patients to adequately fill, in addition to competing with NPs willing to hand out benzos and stimulants for a $25 copay.

Start up costs are low. No EMR, billing company, or secretary needed. Lots of offices in psychiatric suites available to sublease by the hour, day, or month at surprisingly cheap rates. No need to commit to a lease when starting a practice. Office space is widely available because the more psychiatrists are paid, the less they work.

with COVID19 and massive efflux of people out of Manhattan, do you see this continuing in the future?

 

[nexus73]

How does an ethical psychiatrist respond to this?

I’ve heard rumors a certain for profit mega hospital chain would do this. Local facility CEO/head manager would sit in on treatment team and pressure doctors. I guess you tell him/her to stay in their lane, and if they won’t you’d either quit and leave quietly or make a big scene. Or take a voice recorder into treatment and record the corporate manager directing the practice of medicine... then get a lawyer. Or get a lawyer first.