Leaving PP for PE

[hamstergang]

This forum seems very pro-private practice to me, so I wanted to post my story from the other side, having just left a PP for a job funded by private equity. Perhaps I've made a mistake, and if so will update this to warn others in the future. We'll see.

I'm CAP, graduated 8 years ago. My first job was at a large, non-profit, non-academic hospital in the north east, doing outpatient CAP work. I did like the work, had 90 minute intakes and 30 minute follow ups, had some flexibility in my schedule, and got to interact with the Psych Dept along with the Peds Dept (as a CAP, it's nice to mingle with pediatric subspecialists). Most support staff and half of management were good, but others made the job challenging at times. I was also quite busy and had to work some late days to accommodate after-school hours. Responding to phone calls and in-basket messages put me behind in my notes (this was partially my fault for just working slowly). I also had to do phone call and some paid weekend inpatient rounding. Pay was roughly $200 - $270k while I was there.

Then 2 years ago, I started transitioning to a group private practice where I expected to work less, not take call, and get paid more. The biggest draw was that I got tired of the endless meetings at the hospital trying to improve something without ever actually taking action. I did enjoy the freedoms and the 45 minute follow ups. But, even though it was a group practice, it was somewhat isolating (no direct interactions with therapists or the pediatric cardiologists or endocrinologists and the like). I never felt good about charging so much for out-of-network work and not helping much with access to care in the community. I actually felt I needed to be more available to patients given what we charged for visits, so I wasn't much less busy than at the hospital. Some weeks were fine and other weeks it felt like every patient had an issue to call me about. I had to build up a caseload, so pay wasn't as good as planned (and while it was getting there, it was also inconsistent). Sure, I could take off whenever, but if I didn't work I didn't get paid, and I couldn't just take off a random day if patients were already scheduled.

To supplement income while building up, I started working at a residential eating disorders program 9 months ago. This is PE-funded, but I haven't really felt their influence. I like eating disorders work. I liked being part of a team again where I could interact daily with the therapists, dietitians, nurses, and other staff. Visits are flexible -- I have to see each patient once weekly, so I can move around my hours each week as I see fit. I don't have to worry about patients after they leave our facility, so I can be more focused in my work. I can much more easily influence work flows when appropriate compared to at the hospital. Dealing with insurance companies and regulatory issues can be annoying, however.

Keeping up with 2 jobs was getting tough. I recognize that many of my issues with outpatient work and the PP are me issues that I could have worked on, but I feel that residential is already structured in a way that fits me. So, I just left the PP for the residential job. The pay is in the range of $300 - $400k -- the ceiling at the PP was certainly more but this was likely what I would have made if I didn't work myself too hard. There is a risk that PE sells the residential and then lots of things can change. They may also make changes without selling as they obviously are planning to make a profit. While it's easy to find a job as a CAP, I don't want to have to do that. Tune in 6-12 months from now to see if I was crazy.

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[comp1]

Inpatient beats outpatient every time.

 

[clozareal]

Really enjoyed reading about your experience. We definitely need different perspectives about the different types of jobs and careers people can have.

It really highlights one thing that I've always known which is why it's hard to give advice to others about what specialty to choose or what career path to take: the job is about fit.

I love outpatient and inpatient just isn't fit to my work style and personality. I've done enough of it in different settings to know that I don't like it. I know people who hate outpatient, managing their inbox and patient phone calls, and doing therapy. I don't enjoy treating addiction but others love it. So many people hate CAP but I really enjoy working with anxious parents, kids with ADHD, and angsty teenagers. Private practice also isn't for everyone because there's business, administrative, and marketing aspects that people don't care for.

 

[Ceke2002]

This forum seems very pro-private practice to me, so I wanted to post my story from the other side, having just left a PP for a job funded by private equity. Perhaps I've made a mistake, and if so will update this to warn others in the future. We'll see.

I'm CAP, graduated 8 years ago. My first job was at a large, non-profit, non-academic hospital in the north east, doing outpatient CAP work. I did like the work, had 90 minute intakes and 30 minute follow ups, had some flexibility in my schedule, and got to interact with the Psych Dept along with the Peds Dept (as a CAP, it's nice to mingle with pediatric subspecialists). Most support staff and half of management were good, but others made the job challenging at times. I was also quite busy and had to work some late days to accommodate after-school hours. Responding to phone calls and in-basket messages put me behind in my notes (this was partially my fault for just working slowly). I also had to do phone call and some paid weekend inpatient rounding. Pay was roughly $200 - $270k while I was there.

Then 2 years ago, I started transitioning to a group private practice where I expected to work less, not take call, and get paid more. The biggest draw was that I got tired of the endless meetings at the hospital trying to improve something without ever actually taking action. I did enjoy the freedoms and the 45 minute follow ups. But, even though it was a group practice, it was somewhat isolating (no direct interactions with therapists or the pediatric cardiologists or endocrinologists and the like). I never felt good about charging so much for out-of-network work and not helping much with access to care in the community. I actually felt I needed to be more available to patients given what we charged for visits, so I wasn't much less busy than at the hospital. Some weeks were fine and other weeks it felt like every patient had an issue to call me about. I had to build up a caseload, so pay wasn't as good as planned (and while it was getting there, it was also inconsistent). Sure, I could take off whenever, but if I didn't work I didn't get paid, and I couldn't just take off a random day if patients were already scheduled.

To supplement income while building up, I started working at a residential eating disorders program 9 months ago. This is PE-funded, but I haven't really felt their influence. I like eating disorders work. I liked being part of a team again where I could interact daily with the therapists, dietitians, nurses, and other staff. Visits are flexible -- I have to see each patient once weekly, so I can move around my hours each week as I see fit. I don't have to worry about patients after they leave our facility, so I can be more focused in my work. I can much more easily influence work flows when appropriate compared to at the hospital. Dealing with insurance companies and regulatory issues can be annoying, however.

Keeping up with 2 jobs was getting tough. I recognize that many of my issues with outpatient work and the PP are me issues that I could have worked on, but I feel that residential is already structured in a way that fits me. So, I just left the PP for the residential job. The pay is in the range of $300 - $400k -- the ceiling at the PP was certainly more but this was likely what I would have made if I didn't work myself too hard. There is a risk that PE sells the residential and then lots of things can change. They may also make changes without selling as they obviously are planning to make a profit. While it's easy to find a job as a CAP, I don't want to have to do that. Tune in 6-12 months from now to see if I was crazy.

Do you need any more patients? I've known you on here for a while, and I respect your work. Just say the word, and give me a basic run down of the program, and I can pass info onto relevant groups who might be looking for treatment options.

 

[Merovinge]

PHP/IOP and to a somewhat lesser extent RTC are the most popular jobs I see young CAP attendings taking for many of the reasons you mentioned. I would rather work for a doctor owned one generally over a PE owned one and I do expect the PE claws to worsen after the first flip 5-7 years after initial acquisition. Others have been owned for a while (looking at you ERC) and I do think they still provide pretty good care on average.

Let us know how it goes if PE flips to another PE.

 

[djo208]

I think that, rather than inpatient being better than outpatient or vice versa, or working for yourself versus working for someone else being better or vice versa, each choice has benefits and downsides, some of which appeal to one person more while others appeal to another. I personally do inpatient CL work as an employee of an institution AND I do outpatient private practice.

Regarding inpatient, I love the relatively controlled environment of the hospital where assistance, specialty medical services, and the group mind are readily available. I love the diverse range of patients and conditions that I see on a CL service, which keeps me engaged. The benefits were nice when I was full-time there. I also love the social interactions and opportunity to teach in the hospital, the ready opportunity to collaborate on academic projects in the medical school, the opportunity to help a lot of low income and uninsured patients who cannot afford to see a private psychiatrist, the networking and meeting of many new people over the years, and I love the opportunities to learn from others for being in an academic environment. In outpatient private practice, I love having control over my own schedule, being able to integrate long-term psychotherapy with long-term medication management, and the time to do long evaluations and long follow up sessions routinely.

For me, doing BOTH inpatient employment and outpatient self-employment is a winner, but some people don't want both or don't want one or the other. Everyone has to find their own niche. One of my former supervisors used to point out that whatever job you start out with doesn't have to be for life. You can either work to change the job if it's not to your liking or you can go work somewhere else.

I applaud the original poster for working to figure out what works for you. Even if it turns out not to be the right choice, at least you'll have more data for having tried it, which will help you optimize your situation down the line.

 

[manly_man246]

I was burning out w/ my outpatient gig until I picked up some inpatient moonlighting. I agree that doing both really gives a sense of balance and appreciation for what is and isn't greener on the other side. I think. I think your takeaway from this @hamstergang is that more medically complex or multidisciplinary employed (W2) practices are a good fit for you - this can be embedded MH into specialty outpatient clinics, academic - adjacent outpatient, or specialty inpatient services like ED. I hope for you that the PE doesn't let profit tail wag the clinical dog too hard. The fear with working for PE owned groups is turnover/fundamental practice-altering changes on far more frequent basis than in academia or PP. It's akin but not exactly like (IMO having never worked for PE) to working in tech during a high inflationary period (rounds and rounds of layoffs). While job opportunities abound, the actual process of leaving and then starting another job is always stressful.

We are fortunate in Psychiatry (even w/ PE, midlevels, and the relentless assault of insurance companies on the practice of medicine) to have a breadth of practice settings. Many specialties have 2, maybe 3 distinct career paths, and if they've struck out on those they're usually left with a) working for the insurance company, b) an integrative / lifestyle /obesity medicine fellowship (no knock), and/or c) botox and real estate while complaining about the death of medicine on message boards.