Now the ranking deadline passed -- Is anyone feeling "buyer's remorse" with the ranking...? -- Please be kind

[Sanman]

Well, I'm glad that we agree that people should be compensated better throughout training. Before addressing your second point, I think it's important to state that the hypothetical situations I'm outlining are very much based in reality. The requirement to upend one's life for a year prior to degree conferral absolutely disproportionately impacts underrepresented people with regard to stress, financial cost, etc. I think it's a bit odd that you have not acknowledged this.

I do think that having a doctorate increases bargaining power because having a PhD would allow one to bill independently for the hospital while still receiving supervision and honing a skillset during a clinical internship. It is unfortunate that the field has not been successful in collective bargaining as of late, and I wonder if that (in addition to the rising costs of surviving graduate training) will continue to drive people to find alternative applications for their degrees at certain points during their careers. Ultimately, practicing psychologists would still have the same training - the clinical "internship" - would still be required for licensure. Not sure how much psychologists in other settings (e.g., industry, academia, teaching, etc.) are involved in these efforts anyway.

They should be. Higher clinical salaries would mean higher academic salaries. Look at what business, marketing, and Comp Sci professors are compensated compared to us.

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[Sanman]

The fact that many people are required to move twice in one year while being poorly compensated while our degree is hung over our heads absolutely is an equity concern. I will give just one example. Let's say that a woman matched to a site states away from her husband who could not move because of his much better paying career and she got pregnant a couple of months before starting internship. What are her options? Is her degree now in jeopardy? How would this scenario play out differently if she already was conferred her degree yet required to complete a postdoctoral internship for licensure? Our degrees are flexible and they allow for us to improve our income potential and job flexibility without doing solely clinical work every step of the way. This system was not designed to support people from traditionally underrepresented backgrounds.

While true, the underlying assumption here is that the world, in general, cares about equity when attempting to complete a doctorate in psychology (or any doctorate really). Realistically, there is a line about the world's tiniest violin that likely covers what most people think of this. While I agree with the sentiment, this is not an area I expect to see changes any time soon. This is why I counsel those from lower SES backgrounds and those with more complicated personal situations to consider a licensable masters. Many require a benefactor of sorts to get through the degree (parent, spouse, etc.)

 

[childpsych2022]

While true, the underlying assumption here is that the world, in general, cares about equity when attempting to complete a doctorate in psychology (or any doctorate really). Realistically, there is a line about the world's tiniest violin that likely covers what most people think of this. While I agree with the sentiment, this is not an area I expect to see changes any time soon. This is why I counsel those from lower SES backgrounds and those with more complicated personal situations to consider a licensable masters. Many require a benefactor of sorts to get through the degree (parent, spouse, etc.)

This is potentially one of the worst takes I've seen in a while within our field - counsel people from disadvantaged backgrounds to not pursue terminal degrees. Wow. Certainly inspires more emotion in me than the world's tiniest violin could express.

 

[Sanman]

This is potentially one of the worst takes I've seen in a while within our field - counsel people from disadvantaged backgrounds to not pursue terminal degrees. Wow. Certainly inspires more emotion in me than the world's tiniest violin could express.

You have a better suggestion?

 

[WisNeuro]

You have a better suggestion?

Saddle them with an insurmountable level of debt from a diploma mill?

 

[Sanman]

Saddle them with an insurmountable level of debt from a diploma mill?

And possibly with no licensable degree or skills to earn a living if they don't graduate.

I mean, they don't usually need convincing of that. It is the default plan.

 

[cara susanna]

To address an above question, even the research-oriented internships are still majority clinical. The problem is too that it's only a year, so it's not much time to really complete a research project. I matched to a site with a strong research program and was looking for research-oriented internships, as I mentioned. How much research did I do on internship? Zero, lol. And I still matched to a research post doc. Your best bet for internship research is to match to a site that has an established lab and get hooked up with an existing project. That's what the interns at my post doc site did.

 

[bcliff]

You have a better suggestion?

I don't discriminate to whom I do and do not recommend doctoral training in clinical psychology. I do, however, only recommend doctoral training in clinical psychology if acquired through a fully funded program. FWIW, I had a colleague in my program from a low SES background state that our low (< $15k/yr) stipend (with full tuition scholarship, etc.) was the most consistent income he had ever experienced in his life.

 

[bcliff]

From a technical standpoint, most interns are overcompensated when you look at their costs compared to what they bring in. But again, this is a federal reimbursement issue, awarding a PhD earlier will have no effect on this issue.

I'm a little confused by this and think it varies state-by-state. I completed internship and doctoral training in states with midlevel psychology licensure... I don't think billing was ever an issue, so long as I (and other trainees) held that license.

 

[Sanman]

I don't discriminate to whom I do and do not recommend doctoral training in clinical psychology. I do, however, only recommend doctoral training in clinical psychology if acquired through a fully funded program. FWIW, I had a colleague in my program from a low SES background state that our low (< $15k/yr) stipend (with full tuition scholarship, etc.) was the most consistent income he had ever experienced in his life.

The problem with that is the soft costs can add up. Can you secure an apartment on your own with/without additional loans (including internship and post-doc)? moving costs? costs to purchase and maintain a reliable vehicle (to get to school, externships/practica, internship, etc.)? costs for EPPP and study materials? costs for initial licensing prior to a post-doc or job? Plans to support yourself if you need to take an extra year or two to finish dissertation?

That doesn't mean that you can't pursue this profession coming from a low SES. Just realize that these are required and have a plan if you want to pursue this degree because there will not be a lot understanding if you do not meet your obligations. Meanwhile, professions like nursing and social work are much more accommodating to taking leave partially through training. I know nurses that started as nursing assistants and worked their way up to an NP (taking breaks to save money to pay for education along the way). LCSW therapists that started as case managers well. Try that in psychology.

 

[WisNeuro]

I'm a little confused by this and think it varies state-by-state. I completed internship and doctoral training in states with midlevel psychology licensure... I don't think billing was ever an issue, so long as I (and other trainees) held that license.

State is irrelevant when it comes to federal (e.g., medicare) billing, as well as insurers who use CMS guidance. If you are performing the service as part of your training, you cannot bill these payers for the services, unless of course, you are committing billing fraud.

 

[psych.meout]

Well, I'm glad that we agree that people should be compensated better throughout training. Before addressing your second point, I think it's important to state that the hypothetical situations I'm outlining are very much based in reality. The requirement to upend one's life for a year prior to degree conferral absolutely disproportionately impacts underrepresented people with regard to stress, financial cost, etc. I think it's a bit odd that you have not acknowledged this.

Oh really?

Again, you're bringing up a different argument. The compensation and moving for internship, post doc, etc. are separate from whether you get your degree a year early. Yes, what you're mentioning here has to do with equity, but getting your degree before internship doesn't enhance equity.

Between this, misrepresenting what I said about paying psychologists and trainees better, and not addressing any of the flaws in your arguments that I pointed out, I don't think you've actually read anything I've posted.

 

[bcliff]

The problem with that is the soft costs can add up. Can you secure an apartment on your own with/without additional loans (including internship and post-doc)? moving costs? costs to purchase and maintain a reliable vehicle (to get to school, externships/practica, internship, etc.)? costs for EPPP and study materials? costs for initial licensing prior to a post-doc or job? Plans to support yourself if you need to take an extra year or two to finish dissertation?

That doesn't mean that you can't pursue this profession coming from a low SES. Just realize that these are required and have a plan if you want to pursue this degree because there will not be a lot understanding if you do not meet your obligations. Meanwhile, professions like nursing and social work are much more accommodating to taking leave partially through training. I know nurses that started as nursing assistants and worked their way up to an NP (taking breaks to save money to pay for education along the way). LCSW therapists that started as case managers well. Try that in psychology.

I also recommend pursuing either an MSW or MPH, respectively, for more clinically and research oriented students interested in graduate school who are either uninterested in pursuing a PhD or who aren't confident in their ability to attend a fully funded program. I don't delve deeply into the specifics of a student's personal or financial situation when holding mentorship meetings. I will occasionally share with students that I supplemented my full funding in graduate school with additional research and clinical work, which allowed me to make it through my PhD relatively unscathed financially. I also encourage them to look closely at earning potential for various degree paths, as well as the lost income associated with spending more time in school.

State is irrelevant when it comes to federal (e.g., medicare) billing, as well as insurers who use CMS guidance. If you are performing the service as part of your training, you cannot bill these payers for the services, unless of course, you are committing billing fraud.

I'm no expert, but is this still the case if the supervising psychologist is either present or immediately available during the trainee-led visit, reviews all relevant data collected by the trainee, then personally examines the patient, themselves, within 24 hours of the trainee-provided service, if not present during the visit, itself, to confirm/refute the trainee's initial findings, has final say on the patient's course of treatment, and frequently reviews the patient's progress with the trainee while continuing to provide the trainee with regular/recurring supervision, with all of this documented appropriately in the record?

 

[WisNeuro]

I also recommend pursuing either an MSW or MPH, respectively, for more clinically and research oriented students interested in graduate school who are either uninterested in pursuing a PhD or who aren't confident in their ability to attend a fully funded program. I don't delve deeply into the specifics of a student's personal or financial situation when holding mentorship meetings. I will occasionally share with students that I supplemented my full funding in graduate school with additional research and clinical work, which allowed me to make it through my PhD relatively unscathed financially. I also encourage them to look closely at earning potential for various degree paths, as well as the lost income associated with spending more time in school.



I'm no expert, but is this still the case if the supervising psychologist is either present or immediately available during the trainee-led visit, reviews all relevant data collected by the trainee, then personally examines the patient, themselves, within 24 hours of the trainee-provided service, if not present during the visit, itself, to confirm/refute the trainee's initial findings, has final say on the patient's course of treatment, and frequently reviews the patient's progress with the trainee while continuing to provide the trainee with regular/recurring supervision, with all of this documented appropriately in the record?

The supervisor must be physically present while the services are being done, it can be billed.

 

[Sanman]

I'm no expert, but is this still the case if the supervising psychologist is either present or immediately available during the trainee-led visit, reviews all relevant data collected by the trainee, then personally examines the patient, themselves, within 24 hours of the trainee-provided service, if not present during the visit, itself, to confirm/refute the trainee's initial findings, has final say on the patient's course of treatment, and frequently reviews the patient's progress with the trainee while continuing to provide the trainee with regular/recurring supervision, with all of this documented appropriately in the record?

Last I read, Medicare will not pay for any services furnished as part of training. Private insurance will not pay for services, and only a handful of state Medicaid programs will pay.

 

[Dazen]

To address an above question, even the research-oriented internships are still majority clinical. The problem is too that it's only a year, so it's not much time to really complete a research project. I matched to a site with a strong research program and was looking for research-oriented internships, as I mentioned. How much research did I do on internship? Zero, lol. And I still matched to a research post doc. Your best bet for internship research is to match to a site that has an established lab and get hooked up with an existing project. That's what the interns at my post doc site did.

This as been my understand slowly starting to look at internship sites and generally wanting a more research-heavy route. I'm not sure how much it would upend the currently APPIC system for some internships to more formally offer a 2-3 year internship/postdoc option to be matched into, but it would definitely improve productivity and decrease costs, especially considering how much time is lost getting up to speed on the current site's work and then applying/interviewing for postdocs in internship. The compounding influence of spending 2-3 years at one place instead of 1 and 1-2 at two places would create a huge difference in the quality, quantity, and complexity of research that interns/postdocs are putting out. Even if the internship year was still majority clinical, it would set people up much better for postdoc and as early career researchers.

 

[R. Matey]

Absolutely. This is why social work and nursing have a tiered license structure that provides income along the way and the PhD does not. The system was never designed for those people to enter the ranks.

You have a starry-eyed view of what master's level clinicians are paid. Before licensure, it's barely enough to live on, think like somewhere between predoctoral intern to UCC postdoc pay for 2-3 years. The good paying jobs after licensure either involve very high productivity requirements (e.g., Kaiser) or something outside of clinical work completely. And while there are exceptions, few accumulate wealth at the same rate as someone who attended a funded doctoral program.

I don't discriminate to whom I do and do not recommend doctoral training in clinical psychology. I do, however, only recommend doctoral training in clinical psychology if acquired through a fully funded program. FWIW, I had a colleague in my program from a low SES background state that our low (< $15k/yr) stipend (with full tuition scholarship, etc.) was the most consistent income he had ever experienced in his life.

Agree with this, wholly. Many people in our program were first gen and/or came from a marginalized background. All are welcome in psychology.

That doesn't mean that you can't pursue this profession coming from a low SES. Just realize that these are required and have a plan if you want to pursue this degree because there will not be a lot understanding if you do not meet your obligations. Meanwhile, professions like nursing and social work are much more accommodating to taking leave partially through training. I know nurses that started as nursing assistants and worked their way up to an NP (taking breaks to save money to pay for education along the way). LCSW therapists that started as case managers well. Try that in psychology.

Idk I started as a mental health case manager and I'm now a psychologist so it seems possible from my viewpoint. Myself and others also had children during the doctoral program and the faculty were nothing but understanding. My guess is that I'm not alone in that.

 

[Sanman]

You have a starry-eyed view of what master's level clinicians are paid. Before licensure, it's barely enough to live on, think like somewhere between predoctoral intern to UCC postdoc pay for 2-3 years. The good paying jobs after licensure either involve very high productivity requirements (e.g., Kaiser) or something outside of clinical work completely. And while there are exceptions, few accumulate wealth at the same rate as someone who attended a funded doctoral program.

Most doctoral level students in clinical psychology don't attend a funded doctoral program. Those who do are just as likely to succeed in an NP program or DSW as they are in our field. People simply default to clinical psychology. Some might say you have a dim view of what masters level clinicians make. Plenty of good VA jobs for LCSWs and more recently counselors. We used to hire new LCSWs at $55-65k at my old job and psychologists at $85k. I know several with six figure PPs. Masters level training also includes things like school psychology and, until recently, NP/PA programs. Have you seen what NPs make? They're doing fine. Heck, have you seen what Psych RNs make?

Agree with this, wholly. Many people in our program were first gen and/or came from a marginalized background. All are welcome in psychology.



Idk I started as a mental health case manager and I'm now a psychologist so it seems possible from my viewpoint. Myself and others also had children during the doctoral program and the faculty were nothing but understanding. My guess is that I'm not alone in that.

Again, not saying it is not possible. I am minority from a middle class background that got into a funded program. Not saying it cannot be done. However, being a bit older, I also graduated during an internship crisis and into the great recession with post-doc programs collapsing and no jobs. Just because times are good now does not mean it will always be that way. I also include the many people considering unfunded PsyDs in this discussion and I know plenty of folks from minority and low SES backgrounds that regret going this route.

As a field, we need more diversity and it is nice to see those form differing backgrounds join our ranks. However, there is a reason you see a lot of first gen immigrants in fields like nursing and not psychology. The barriers to entry are lower and the salaries are higher. I think we have a responsibility to young students to ensure that they make the best decision for themselves as this is not a risk you often get multiple changes to get right. Mess it up once and you might be buried in debt for life. I think it is okay to admit that other fields might have some advantages over ours.

 

[R. Matey]

Most doctoral level students in clinical psychology don't attend a funded doctoral program. Those who do are just as likely to succeed in an NP program or DSW as they are in our field. People simply default to clinical psychology. Some might say you have a dim view of what masters level clinicians make. Plenty of good VA jobs for LCSWs and more recently counselors. We used to hire new LCSWs at $55-65k at my old job and psychologists at $85k. I know several with six figure PPs. Masters level training also includes things like school psychology and, until recently, NP programs. Have you seen what NPs make? They're doing fine. Heck, have you seen what Psych RNs make?

I've often wondered why we decry the midlevel professions for their poor quality control and takeover of clinical jobs while simultaneously recommend these programs to people. I've done it myself so I'm no better, but I have reflected on the inconsistency in the messaging on this board. Is there really anything wrong with someone who is capable of reading the research and competently differentiating complex symptom pictures who ends up in a psychotherapy private practice? For myself, not being able to understand the latest developments in the field made me a dilettante in practice hence the need for more training in research and assessment became obvious. But, then again, I also really don't like people telling me what to do.

Secondly, Maybe our views are just different. Yours maybe an upwardly skewed restricted range: most mental health counselors and many social workers don't work in the VA (as you note, counselors weren't even allowed to work there until recently so how would you know what counselors make?) and I'm guessing you don't rub shoulders with too many clinicians in community mental health. Most of the people I graduated with either have left the counseling field for something else or are in private practice making about the starting salary of a psychologist at your old job, and that's considered really successful. I suppose someone could make the same as a teacher and get an Ed.S. degree to do assessments that people don't respect (see the psychiatry forum) or go be a medical extender of some kind. These are all high burnout jobs though, and there's nothing wrong with reaching for better if you can (meaning you attend a funded program).

Is psychology always the best choice career-wise? No, and I didn't say as much. Financially, you would gain more way more upward mobility by going into tech, finance or engineering. I think the point of earlier posts though is to respect people's right to self-determine in their career choices regardless of their background.

 

[Sanman]

I've often wondered why we decry the midlevel professions for their poor quality control and takeover of clinical jobs while simultaneously recommend these programs to people. I've done it myself so I'm no better, but I have reflected on the inconsistency in the messaging on this board. Is there really anything wrong with someone who is capable of reading the research and competently differentiating complex symptom pictures who ends up in a psychotherapy private practice? For myself, not being able to understand the latest developments in the field made me a dilettante in practice hence the need for more training in research and assessment became obvious. But, then again, I also really don't like people telling me what to do.

I don't consider it an inconsistency at all. There is no good master's level psychotherapy path because counseling has more on point training but sw has better lobbying and job outlook. However, those are only two of many options.

At the end of the day, college kids are coming out with more undergrad loans than I had for my whole education. Decisions need to be made about the financial realities and that choice does not always line up with the best training.

Secondly, Maybe our views are just different. Yours maybe an upwardly skewed restricted range: most mental health counselors and many social workers don't work in the VA (as you note, counselors weren't even allowed to work there until recently so how would you know what counselors make?) and I'm guessing you don't rub shoulders with too many clinicians in community mental health. Most of the people I graduated with either have left the counseling field for something else or are in private practice making about the starting salary of a psychologist at your old job, and that's considered really successful. I suppose someone could make the same as a teacher and get an Ed.S.
degree to do assessments that people don't respect (see the psychiatry forum) or go be a medical extender of some kind. These are all high burnout jobs though, and there's nothing wrong with reaching for better if you can (meaning you attend a funded program).

Healthcare is high burnout. Plenty of burned out psychologists and physicians as well. I know a few physicians who wish they stuck to midlevel for easier caseloads and less call.

You seem more focused on counselors and LCSWs as the only mid-level professions. Other options skew higher. Some with less education.

Is psychology always the best choice career-wise? No, and I didn't say as much. Financially, you would gain more way more upward mobility by going into tech, finance or engineering. I think the point of earlier posts though is to respect people's right to self-determine in their career choices regardless of their background.

Tech, finance, and engineering have their own issues.

No one is putting a gun to their head and telling them that they cannot apply. People are free to make their own choices. However, most are not educated to the full array of options. Hence all the posts on here. They ask me for an opinion, I will give one.

 

[bcliff]

If you are performing the service as part of your training, you cannot bill these payers for the services, unless of course, you are committing billing fraud.

The supervisor must be physically present while the services are being done, it can be billed.

So, now that we've established it's not billing fraud. How does this applying to billing for "thinking" codes in neuropsychology (e.g., conceptualization, writing, etc.?) -- Does the thinking/writing need to be done in the line of sight of the attending/supervising neuropsychologist?

 

[WisNeuro]

So, now that we've established it's not billing fraud. How does this applying to billing for "thinking" codes in neuropsychology (e.g., conceptualization, writing, etc.?) -- Does the thinking/writing need to be done in the line of sight of the attending/supervising neuropsychologist?

It's not billing fraud if the supervisor is there, but it is a net money loss given that that the supervisor can't do other billable services at that time, and trainees generally take longer to do testing, which is the lowest reimbursements of the billing codes. We cannot bill for trainee report time. We bill for the time it takes us to review those reports.