Niche Specialty Clinic for Economic Success?
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Drop the IP, focus on OP. The unit will hound you all afternoon for tylenol, motrin, trazodone, etc.
OP PP focusing on cash/high-paying insurance products with forensic consulting/expert witnessing on the side.
I believe the demand in general for psychiatric services overshadows any potential gain from developing a niche. However, I suppose you could specialize in finance-related anxiety or "executive coaching" (psychotherapy?).
I believe the demand in general for psychiatric services overshadows any potential gain from developing a niche. However, I suppose you could specialize in finance-related anxiety or "executive coaching" (psychotherapy?).
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Off the top of my head-
1) Intellectual disabilities/autism (especially if child trained) - there is one young psychiatrist doing this in our area, and she does very well for herself. In most areas, outside of specialty academic clinics, there is essentially no one willing to see these patients so she accepts cash only and desperate parents are grateful to pay whatever she asks.
2) Eating disorders - demographic skews more socioeconomically privileged, and again, very few people specializing in this
3) Forensics - not everyone gets there, but the top professionals in this field make an enormous amount of money
4) Impaired professionals - people with a lot to lose will pay quite a bit of money to get good treatment and avoid leaving an insurance/hospital system record paper trail. There are several such clinics I'm aware of scattered around the east coast.
1) Intellectual disabilities/autism (especially if child trained) - there is one young psychiatrist doing this in our area, and she does very well for herself. In most areas, outside of specialty academic clinics, there is essentially no one willing to see these patients so she accepts cash only and desperate parents are grateful to pay whatever she asks.
2) Eating disorders - demographic skews more socioeconomically privileged, and again, very few people specializing in this
3) Forensics - not everyone gets there, but the top professionals in this field make an enormous amount of money
4) Impaired professionals - people with a lot to lose will pay quite a bit of money to get good treatment and avoid leaving an insurance/hospital system record paper trail. There are several such clinics I'm aware of scattered around the east coast.
I agree with focusing on outpatient. I know of one group in my state that will pay around $70 per WRVU, and in an outpatient practice doing 30 minute follow-ups billing a 99214 + 90833, you could generate a lot of cash. You have to consider that you'll have no shows and cancellations though, so factor that in. You also have to figure out a way of doing med management with psychotherapy that leaves you comfortable billing for psychotherapy add-on codes. However, if you do the math you can see that this model can result in a pretty handsome take home paycheck If you're willing to do 40 plus patient care hours per week with limited time off.
Even just focus on anxiety.
Second the neurodevelopmental population idea
Women's health only clinic
Men's health only clinic
Hypnotherapy
Neurostimulation: ECT/TMS/Ketamine
A ways from me is geriatric specific type of clinic
Forensics side for determining letters for emotional support animals, as a declaration of disability is needed. Be the go to ESA person...
Or go find a specialist group like OB/GYN, and convince them to let you join their group and be *their* psychiatrist, to get all their women's health. Can do the same thing with a neurology group and get all the epilepsy, HD, PD, etc cases. Or a cardiology group and get all the CABG/Cath/CHF cases. Chances are most groups in most locations would only fill you ~0.5FTE or so.
Long story short at one point I had a OB group consider back dooring the hospital politics to hire me themselves.
Build from the ground up a chronic pain rehab modeled after what Cleveland Clinic / Mayo / Hopkins have. Do an elective or fellowship at Cleveland and you'll get the idea of what it would take to build a program - the most limiting factor is the Psychiatrist who wants to focus on Chronic Pain (non interventional, naturally). Set one of those programs up in any town with 100k+ population draw, BUSY.
I caution ED clinic as those typically are best with full wrap around programs with residential, PHP, IOP, etc
Same thing with doing a niche addiction, unless focusing on med management side for AUD/OUD. So much of this population benefits from the higher level of care early on.
Caution also with doing too much of a niche. 35+ hours a week of super specialized can be well, draining. Some diversity is nice.
Second the neurodevelopmental population idea
Women's health only clinic
Men's health only clinic
Hypnotherapy
Neurostimulation: ECT/TMS/Ketamine
A ways from me is geriatric specific type of clinic
Forensics side for determining letters for emotional support animals, as a declaration of disability is needed. Be the go to ESA person...
Or go find a specialist group like OB/GYN, and convince them to let you join their group and be *their* psychiatrist, to get all their women's health. Can do the same thing with a neurology group and get all the epilepsy, HD, PD, etc cases. Or a cardiology group and get all the CABG/Cath/CHF cases. Chances are most groups in most locations would only fill you ~0.5FTE or so.
Long story short at one point I had a OB group consider back dooring the hospital politics to hire me themselves.
Build from the ground up a chronic pain rehab modeled after what Cleveland Clinic / Mayo / Hopkins have. Do an elective or fellowship at Cleveland and you'll get the idea of what it would take to build a program - the most limiting factor is the Psychiatrist who wants to focus on Chronic Pain (non interventional, naturally). Set one of those programs up in any town with 100k+ population draw, BUSY.
I caution ED clinic as those typically are best with full wrap around programs with residential, PHP, IOP, etc
Same thing with doing a niche addiction, unless focusing on med management side for AUD/OUD. So much of this population benefits from the higher level of care early on.
Caution also with doing too much of a niche. 35+ hours a week of super specialized can be well, draining. Some diversity is nice.
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Really good bits of advice. Much appreciated. I was however under the assumption you could do quite well with inpatient, I recall some forum members talking about this at some point.
And I'm guessing with all these outpatient gigs I'd have to market pretty heavily and wait a year or two to get full considering cash practice. And for reference, I'm hoping to move home to California when I finish.
And I'm guessing with all these outpatient gigs I'd have to market pretty heavily and wait a year or two to get full considering cash practice. And for reference, I'm hoping to move home to California when I finish.
And how do you go about making a name for yourself as the anxiety guy... Or _____ guy? How do people find out that is specifically what you're specializing in?
This kind of thread keeps popping up it's starting to get annoying. I hope you go to a top program because if you go to a FMG heavy program it doesn't matter what you do during PGY4 it'll be tough for you to be able to recruit patients in the cash-only market. Otherwise do a search, all the information is all there in historical threads.
I agree. 90-95% of all residents will make average to median salaries as they all generally want to work under 40 hours in an employed model. The OP answered his own question of IP/OP combo. If your willing to do 7-12 inpt and 1-6 outpatient your work ethic will get you there there's nothing else you need to do special. Do that and the connections you make from all that work will lead you far.
And some of them work for super sketchy companies. Would never tie my name/reputation to something like this.
so u go to a mid tier program, dont want to see high volume of patients, want to move to california, and want to make a lot of money by working in a niche that you dont know yet but maybe an online forum will guide u toward?
unless something changes i dont see this as a recipe (so far) for great financial success in the field
unless something changes i dont see this as a recipe (so far) for great financial success in the field
I don't want to provide sub par care by seeing 50 inpatients a day for a few minutes each. I said I'm happy doing 50 hours a week however. I would think that would provide enough volume to do well financially, no?
I was in your position as a PGY-3. I thought very hard about being creative or figuring out a way to "make a niche." As an attending now, I appreciate that there are maxing your financial income AND lifestyle (easy hours, rewarding patient interactions, autonomy, low call, etc). To have one of the two in this field is easy. For instance, one way to make a lot of money not mentioned so far is to basically stack a bunch of locums assignments or as other's have said, build a mental health clinic. To me, this lifestyle sucks. Having business savvy, offering good care, and being efficient can definitely get you in the 300-400k range as a solo provider. IMOH, to get past that, you're welcoming more stress (larger overhead, more liability, more people, less autonomy, etc).
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I think you are asking the wrong questions. You can’t develop a more lucrative niche that draws patients on a local level that works for all markets. For example: Had I chosen a niche in my current location, my cash practice would likely be a bust. There was room for a C&A doc to walk right in and draw all concerns. Had I chosen a different location, a niche may be helpful, but I certainly wouldn’t want to be an eating disorders specialist near the closest well regarded eating disorder center. I’d likely lose that battle.
You need to first determine your market, research it, figure out what needs aren’t being met, and then tailor your practice to fill demand.
Eh, sometimes threads are out of date. It helps others like me when these discussions get renewed every couple of years but it keeps me up to date. 🙂
There are threads I don't like either and I just move on and not comment in them. 😛
It depends on what you mean by doing well? Compared to the vast majority of the American population, we ALL do well financially. Most people make less than half of what we make on average. Can you find a decent job with work/life balance in psych in the $250 - 300K range? Yes. Can you find one for upwards of $500K? Sure, by sacrificing lifestyle. Can you put together a ton of other things to make up that extra 200K without sacrificing lifestyle? Yes, but that's all about business acumen and skills aside from patient care and medicine. Do you have those skills? Only you can answer that.
One way to make money, as a previous poster said, is locums work. You can make tens of thousands in a few weeks doing locums work, but you will have to choose the assignments carefully if you truly don't want to provide sub-par care.
If you choose locums, there are three ways to do this:
1. Sign with a national company who can get you locums work all over the country. This will be your fulltime gig. Your job will be to travel to wherever the assignment is (usually they pay your travel and housing expenses, they get you licensed, and pay your malpractice). You typically will spend a 2 weeks - month at that location acting as a psychiatrist and the number of patients, etc. will vary depending on where you are. You can make a lot of money doing this and take time off as needed. Some people work for a month, then take a month off, rinse and repeat.
2. Work a regular full-time job, then take vacation time to do the locums thing for a few weeks. What sucks about this option is that you'll be flying through vacay time and still working, but you'll be doubling your income. As I said, you can early tens of thousands doing locums work for a few weeks with the right assignment.
3. Do weekend locums work. You can do weekend rounding on inpatient units over the weekend and if you're doing it through a locums company, you'll be protected in terms of what you're responsible for and they'll pay your malpractice. Depending on the assignment, you can make a lot of money. Doing typical rounding 8-5 Saturday and Sunday (on 20+ patients) can get you around $1500-2000 a day. Overtime can get you more, but at the least you'll be making around $3000+ a weekend. If you provide 48-hour in-house coverage (sleeping there), you can make a lot more (heard around $7,000 - $10,000 a weekend). Not bad, if you're willing to do it.
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Forensics/Expert witness is NOT conducive to having a great schedule.
1) Courts (not depositions) do not schedule based upon convenience. This means you can be notified that you'll be called to testify either next Tuesday or maybe Wednesday. It is difficult to do other work on that schedule.
2) If you're good, you'll get referrals. If you decline due to time constraints, new referrals will not call you again. This means you'll have to sometimes take on a ton of work when your plate is already full.
3) If you start getting multiple state/site referrals, you end up going all over the place with the aforementioned schedules. Some of those referals are difficult to turn down. It would be difficult to refuse an offer to pay your forensic rate for a flight to Alaska
4) In the middle of trial, attorneys like to have dinner meetings. Which suck, if you've been sitting out in the hall of a court room for 6 hours.
5) There is not a steady stream of income. There are marketing aspects to this.
1) Courts (not depositions) do not schedule based upon convenience. This means you can be notified that you'll be called to testify either next Tuesday or maybe Wednesday. It is difficult to do other work on that schedule.
2) If you're good, you'll get referrals. If you decline due to time constraints, new referrals will not call you again. This means you'll have to sometimes take on a ton of work when your plate is already full.
3) If you start getting multiple state/site referrals, you end up going all over the place with the aforementioned schedules. Some of those referals are difficult to turn down. It would be difficult to refuse an offer to pay your forensic rate for a flight to Alaska
4) In the middle of trial, attorneys like to have dinner meetings. Which suck, if you've been sitting out in the hall of a court room for 6 hours.
5) There is not a steady stream of income. There are marketing aspects to this.
For what it's worth, I'm in an employed position at an academic center and moonlight in our ED (anywhere from 12-24 hours/week, depending on shift availability) and expect to gross about $300k. This is working 6 days/week (sometimes 7) and occasional evening ED shifts until 11pm on weekdays. In terms of actual working hours, I would say I work 50-60 hours/week. However, my actual work days outside of the ED are fairly short. For example, today I will probably be done by 11am after getting here at 7am. I'm doing some teaching activities with medical students that will keep me here until 4pm, which I really enjoy and is important to me. Some days are longer, but even then I am rarely at the hospital after 4pm.
If you are willing to work lots of hours, the sky is the limit in terms of your income, even in employed positions. If I were to work 70+ hours/week doing only ED work at our academic center/county hospital, I could probably clear $400k gross. The problem is that sucks and would not be sustainable in the long run - and I say that as someone who loves working. The question is how much you want to work and how much you're willing to sacrifice to make whatever amount of money you want to make.
An attending here who works in the ED has a primary locums job of outpatient telepsych as well as ED shifts. She works like a dog and I'm guessing makes a very good amount of money, but she is literally working all the time. Not my cup of tea, but if you're willing to do that your income can be quite good.
If you are willing to work lots of hours, the sky is the limit in terms of your income, even in employed positions. If I were to work 70+ hours/week doing only ED work at our academic center/county hospital, I could probably clear $400k gross. The problem is that sucks and would not be sustainable in the long run - and I say that as someone who loves working. The question is how much you want to work and how much you're willing to sacrifice to make whatever amount of money you want to make.
An attending here who works in the ED has a primary locums job of outpatient telepsych as well as ED shifts. She works like a dog and I'm guessing makes a very good amount of money, but she is literally working all the time. Not my cup of tea, but if you're willing to do that your income can be quite good.
I'm not saying that advice, or what the OP is asking about "niche" is wrong, but frankly we are doctors not MBAs. I would take that elective time to see what population really clicks with you, who you naturally have strong rapport/empathy with, and build that into a successful practice. If you're excellent at what you do, the patients really will come. Its going to be harder if your nice is ED next to the best ED center that Saudi prince's fly into, but even then it sounds like OP has some geographic flexibility.
97% or greater of all the things talked about are already posted and can be found by searches. This could be the default answer for everyone.
Reserving this response for a repeat poster who keeps asking the same question is best to refer to the search feature.
I believe even less prestigious residencies can still yield to a cash only practice. Considering the rising levels of ARNP. Psychiatrists > ARNP
You think 70 hrs a week grossing 400 is good? That is the least effective money making balance I’ve probably ever heard lol
Continue to ask questions. Some programs have staff docs who thing talking business is taboo. Hopefully the things you learn here prime your thoughts for further investigation.
Also consider the growth of the medical education pathway. Entering medical school "oh my gosh, I won't be able to do xyz anymore, I will only be a doctor am I sure?"
Pursing residency "oh my gosh, I won't be able to be a cardiologist, general surgeon, am I sure?"
Leaving residency "oh my gosh, I won't be a C&A, Forensics, etc, am I sure?" "shouldn't I be closing more doors now? Is being a general psychiatrist truly enough?"
Yes, being a general adult psychiatrist is truly enough and even in a saturated market you can still build a practice with standards and quality and word will spread to patients and referral sources you are better than other XYZ options. Success!
Pick some thing that motivates you and run with it.
Then don't.
There is nothing inherently ethically suspect in treating impaired professionals. It's necessary and valuable work. As with all jobs, investigate thoroughly for sketchiness before signing on. Or the OP might start his own practice, which is more the vein I assumed we were talking about.
For work at an academic institution, sure. I'm sure you could probably make much more with the same amount of time in the PP setting.
I work at a private psych hospital. The only way to hit the 400-500k mark at my hospital is by working 70-80 hours a week.
Thanks for giving me a lot to think about. I'd love to do weekend work maybe once a month where I'd spend 48 hours in the building. Are those numbers you quoted common and easy enough to have a locums company set you up with semi regularly?
You seem to have very unusual and inaccurate expectations about this field and the income those in it can generate. Can you make more than $400K working 70 hours a week? Sure, but that's more the exception, not the rule, and would never apply to academics.
No one said there was anything "inherently" ethically wrong with it. But some places catering to treatment of impaired physicians also take advantage of the level of vulnerability in those trying to protect their livelihood and reputation by bypassing traditional treatment.
I don't know how common they are in, say, the cornfields of Indiana, but I know two people in metro East Coast markets who do the 48-hour in-house coverage regularly. From what I know/heard, it's usually the for-profit hospitals with 100 beds that offer this type of payment.
That said, if you didn't want to do the 48-hour thing with 100 patients, you can always work every other weekend, rounding on 20-something patients and still make an extra $6000 - $8000 a month.
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I met a guy who was charging something like $1500/hr to do family therapy with anorexic pts and their families. He worked like 2hrs/day doing that and half-time was the PD for the CAP fellowship making whatever comparative pittance.
This is only good for making $$ if most of the patients who speak that language have $$$. (Mandarin in Vancouver.)
Agreed. This is popular in the big east coast cities.
Julie Holland covered the Bellevue CPEP just on weekend nights for years and wrote a book about it that got some buzz:
Weekends at Bellevue by Julie Holland: 9780553386523 | PenguinRandomHouse.com: Books
“A gem of a memoir . . . Holland takes us for a ride through the psych ER that is at once wild and poignant, a ride that leaves deep tracks in even the healthiest of minds.”—Katrina Firlik,...
www.penguinrandomhouse.com
Agreed. This is popular in the big east coast cities.
Julie Holland covered the Bellevue CPEP just on weekend nights for years and wrote a book about it that got some buzz:
Weekends at Bellevue by Julie Holland: 9780553386523 | PenguinRandomHouse.com: Books
“A gem of a memoir . . . Holland takes us for a ride through the psych ER that is at once wild and poignant, a ride that leaves deep tracks in even the healthiest of minds.”—Katrina Firlik,...
Should one be able to find this in big metros on the west coast/CA?
Are you employed at an academic center?
Covering weekends on an inpatient unit, yes. A friend of mine is a psych nurse in California and they're always looking for psychiatrists to round on the weekends.
Emergency psychiatry, not sure. The CPEP (New York) model (more of a classic ED structure) is the gold standard on the east coast. The Alameda (Oakland) model (local EDs transfer to a regional hub for immediate evaluation) is more popular on the west coast. I have a great deal more experience with the former.
Trying to discern the relevance in that question.
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I'm sure in that case he could go to one of those ridiculously noncompetitive fellowships at "elite" institutions who would basically be happy to have any kind of cheap labor for a year. Do you think patients would know the difference? It's really not that difficult to have your name connected to x or y.
I actually don't think the name is that critical as you suggest for private practice. Reputation in the community and with colleagues is the deal breaker. Connections kill it. Plenty of graduates from top 10 places are poor psychiatrists/professionals and patients will run away and plenty of graduates from FMG heavy places are not.
You very much strike me as an employed academic center type person so I wanted to see if my hunch was on point
This is a viable strategy (i.e. fellowship). I agree going to a top 10 is helpful but neither (strictly) necessary nor sufficient. I was just irritated by the original post as literally two posts down someone was trying to "stack jobs", and then another two post down another post was exactly the same...
Ways to make more money in medicine:
1. Volume
2. Collect more from each pt encounter
3. Go somewhere no one else wants to go and have the org/gov subsidize the salary above normal market forces
Volume: See more patients. To do it well will require you to work longer hours, supervise mid levels, or give substandard care. Your choice.
Collect more: People are willing to pay more if they deem you offer something the lower cost options do not, or offer something unique few others can provide. Private insurance pays better than public. Cash only seems to do even better still. Other option is to have your lobbying group get in the ear of those who determine CMS rates but unfortunately for non-procedural based specialties, we get kind of hosed.
Go somewhere: There is ALWAYS a good reason these places have a hard time attracting help and you will typically earn every penny.
There is no trick to earning more. The highest earners in every specialty are the ones that work the most and/or are the best at what they do and/or offer something few others do and/or have marketed themselves in a way that enable their high salary.
1. Volume
2. Collect more from each pt encounter
3. Go somewhere no one else wants to go and have the org/gov subsidize the salary above normal market forces
Volume: See more patients. To do it well will require you to work longer hours, supervise mid levels, or give substandard care. Your choice.
Collect more: People are willing to pay more if they deem you offer something the lower cost options do not, or offer something unique few others can provide. Private insurance pays better than public. Cash only seems to do even better still. Other option is to have your lobbying group get in the ear of those who determine CMS rates but unfortunately for non-procedural based specialties, we get kind of hosed.
Go somewhere: There is ALWAYS a good reason these places have a hard time attracting help and you will typically earn every penny.
There is no trick to earning more. The highest earners in every specialty are the ones that work the most and/or are the best at what they do and/or offer something few others do and/or have marketed themselves in a way that enable their high salary.
I think one way to do it is to call a pp psychiatrist and ask to be a partner but with a different site.
This way you don't steal their patients but have their credentialing etc.
Pay them some amount of money to do this and offer to help with call, staffing etc.
This way you can be established easier.
Large groups will bleed you dry.
This way you don't steal their patients but have their credentialing etc.
Pay them some amount of money to do this and offer to help with call, staffing etc.
This way you can be established easier.
Large groups will bleed you dry.
I mean, in a lot of areas people are so desperate for anyone decent that they'll pay cash to the first person who pops up. If you want to do PP/Cash only in Boston or NYC you might have a problem, but as the only person doing autism in a 150 mile radius or as the only person in the area that's not a part of the big groups that shuffle patients in and out after 15-20 minutes? You have to be good at marketing and finding a niche, to be creative and know how to sell yourself.
To some degree, just being a physician is a niche. The rising tide of ARNP, I've had patients specifically come to me wanting the real deal Psychiatric expert out of frustration of past ARNP experiences. And these were not expressions of narcissism but legitimate concerns.
One of my colleagues received a psych consult from a PA because the pt didn't want to see the PA but an MD/DO. The PA thought the pt had some psych issues because they didn't want to be seen by a PA.
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That's exactly what that wasteful consult was for.
I’m going to disagree with the suggestion there’s lots of money to be had in noninterventional pain; unless you want to run a pill mill, there isn’t.
While trying to get a clinic going, I'm trying to feel out what kind of locums I might be able to find to hold me over until I'm busy enough to pay the bills. Are there typically ED/inpatient/telepsych shift assignments? 12 hours x 180-200/hr? It would be great to do 2 12's a week then focus on a clinic the rest of the time.
I get about 120/hr moonlighting, but with all my loans I'm not sure that will cover it once I'm done with residency.
I get about 120/hr moonlighting, but with all my loans I'm not sure that will cover it once I'm done with residency.
It’ll be location specific, but most PT gigs around me are about $140/hr.
That's disheartening. Would being in a coastal area affect this positively? My understanding was that locums jobs paid more..
