Offer Letter First Attending Job

[Monocles]

Seems like you are a seasoned attending and I value your advice ( as well as the other members in this forum). What do you think about starting your career as a junior attending in academic hospital vs private or community practice. So far, I have 6 offer letters in front of me in various settings and I am having very hard time to pick one. I always thought academia as an ideal setting to step in attending realm due to career advancement, learning opportunities and supervision from more experienced faculty. I do feel like in community mental health setting, advancement opportunities would be limited ( I guess the top position would be advancement to medical directorship after 20 years of service?). With private practice, the only advancement I see is buying in the practice or opening your brand new one but unless you create a brand practice like Talkiatry, Amen clinics or Lifestance (which are mostly managed by corporations or like minded people unfortunately) my horizon does not extend further after being an owner or a partner.

The only continuous career-wise lifelong advancement I see is in academia. I would like experienced and seasoned psychiatrist to give their insight in this thread. Money and benefits are must but I do feel like at some point ( probably less than 5 years) , they wont mean much , boredom will sink in and lead to eventual burn out. Maybe that`s why Medscape survey revealed that physicians in academia are less likely to be burned out?

You're too kind. Full disclosure I am only one year ahead of you, friend.

It sounds like you have several great options - I would ask yourself what is most consistent with your personal values. One thing I want to point out is that by virtue of having gone through med school and training programs, there is a strong bias towards academia (aka the academic kool-aid) because that is near 100% of what we are exposed to as models. Many years back when I was interviewing at a "brand name" fellowship, I brought up an observation that many grads seem to stay on as academic faculty. The interviewer actually got very offended that I would even mention it, and said "any psychiatrist worth their salt would dedicate their career to academia! only FAILUREs who can't hack it set up shop in suburbia". Of course that institution was in some ways an extreme, but I think it shows how the extent of the bias.

In my time interacting w/ other psychiatrists in our local area, I've found that the happiest ones tend to be ones who work part-time (most often in community hospitals or private practice). I would encourage you to speak with some psychiatrists in your local area who are NOT in academia just to see if they like it or not.

EDIT: Also keep in mind the average length of a "first-job" for psychiatrists out of training is 2 years. (The emphasis being that HALF don't even stick around for that long!) So no matter what you end up picking, if it ends up being a poor fit you can always leave. It's not like training where you are basically in indentured servitude, lol.

EDIT2: wow splik said everything I wanted but much more eloquently. I would read his thoughts!

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[MedMan80]

You're too kind. Full disclosure I am only one year ahead of you, friend.

It sounds like you have several great options - I would ask yourself what is most consistent with your personal values. One thing I want to point out is that by virtue of having gone through med school and training programs, there is a strong bias towards academia (aka the academic kool-aid) because that is near 100% of what we are exposed to as models. Many years back when I was interviewing at a "brand name" fellowship, I brought up an observation that many grads seem to stay on as academic faculty. The interviewer actually got very offended that I would even mention it, and said "any psychiatrist worth their salt would dedicate their career to academia! only FAILUREs who can't hack it set up shop in suburbia". Of course that institution was in some ways an extreme, but I think it shows how the extent of the bias.

In my time interacting w/ other psychiatrists in our local area, I've found that the happiest ones tend to be ones who work part-time (most often in community hospitals or private practice). I would encourage you to speak with some psychiatrists in your local area who are NOT in academia just to see if they like it or not.

EDIT: Also keep in mind the average length of a "first-job" for psychiatrists out of training is 2 years. (The emphasis being that HALF don't even stick around for that long!) So no matter what you end up picking, if it ends up being a poor fit you can always leave. It's not like training where you are basically in indentured servitude, lol.

EDIT2: wow splik said everything I wanted but much more eloquently. I would read his thoughts!

Splik is basically a walking logic machine, I welcome his posts..

 

[elbandito1]

Just trying not to get swindled here, but what’s a reasonable pay for an adult inpatient gig with academic appointment in the north east? I’m in the low 200s with average 10-12 patients and it can get very busy. This Is my first attending job and seeing this post makes me think I should have asked for more (though I’m not CAP and get that’s probably a factor). People saying 300+ base is reasonable makes me think maybe I should have negotiated better!! lol

 

[FlowRate]

Just trying not to get swindled here, but what’s a reasonable pay for an adult inpatient gig with academic appointment in the north east? I’m in the low 200s with average 10-12 patients and it can get very busy. This Is my first attending job and seeing this post makes me think I should have asked for more (though I’m not CAP and get that’s probably a factor). People saying 300+ base is reasonable makes me think maybe I should have negotiated better!! lol

Other people will have more informed answers but the academic positions I knew about in Boston hospitals were lucky to crest 200k as of a couple years ago. There was some room for salary negotiation especially if you had a clear BATNA. Most of the negotiation was around research time or exactly what FTE someone would work while building a side private practice. Or what your title would be if in a niche research field. Or if you'd get to have your own office instead of sharing one.

 

[calvnandhobbs68]

Other people will have more informed answers but the academic positions I knew about in Boston hospitals were lucky to crest 200k as of a couple years ago. There was some room for salary negotiation especially if you had a clear BATNA. Most of the negotiation was around research time or exactly what FTE someone would work while building a side private practice. Or what your title would be if in a niche research field. Or if you'd get to have your own office instead of sharing one.

Omg this was one of my biggest pet peeves of academic places. The junior attending's office is a shared office stuck next to the janitor closet with no windows or something. While one of the NPs gets one of the biggest window offices in the building. F that crap.

 

[Monocles]

Other people will have more informed answers but the academic positions I knew about in Boston hospitals were lucky to crest 200k as of a couple years ago. There was some room for salary negotiation especially if you had a clear BATNA. Most of the negotiation was around research time or exactly what FTE someone would work while building a side private practice. Or what your title would be if in a niche research field. Or if you'd get to have your own office instead of sharing one.

Flowrate you've been in the system a few years longer than I have - any advice for renewal negotiations?

 

[FlowRate]

Flowrate you've been in the system a few years longer than I have - any advice for renewal negotiations?

Edit: Pretty sure we have very similar experience at these hospitals except I never worked as an attending in Boston so at this point you may be better informed than I am! Most of the advice I got previously was from people negotiating their position to start, not renegotiating. PM'd you to follow-up.

 

[SourceOfDenial]

Just to pile on— having 0.1 FTE set aside for ‘academic time’ is a joke. You will just spend that finishing notes. They are basically paying you less for a full time clinical load and have no desire to provide any way that’s meaningful for you to advance in terms of teaching/mentoring etc. You aren’t doing research with 0.1 FTE, unless you are doing it on your own weekends/evenings.

 

[splik]

Omg this was one of my biggest pet peeves of academic places. The junior attending's office is a shared office stuck next to the janitor closet with no windows or something. While one of the NPs gets one of the biggest window offices in the building. F that crap.

my first office as an attending was a utility room shared with 2 other new attendings. absolutely awful. I spent so much time negotiating for one thing, I didn't even think about this. I had to literally take over someone else office as they were leaving to get my own office. I learned from some of the support staff I could have asked for an imac, and ordered furniture, lighting, and art work for my office! If only. Most of the faculty bought their own furniture (I stole some old furniture from the analysts) for their office. Once I learned the account codes, I just started ordering stuff and billing it to the department. which it turns out they were fine with.

 

[Marasmus1]

The offer is revised by the hospital after some back and forth negotiations.

They took the outpatient off the table so at this point this is strictly full time inpatient.

I was able to negotiate down from average 14 patients to strict cap at 12. They won`t start me at 12 and will have me build up from 6 to 12 in 6 months.

Instead of 1:3 weekend coverage, was able to go down to 1:4 weekend coverage with any additional coverage optional and with extra compensation

They also told me that at any point I will either have a resident/fellow or both to help with the load. I would not like to give more than 4 patient to a resident and 6 to a fellow due to educational objective over service but even then I am hoping that it would alleviate some load?

From Average 14 patients to cap at 12 and 1:3 weekends to 1:4 weekends, my overall compensation took some hit from 340k to 310k. The bonus and the other benefits and reimbursements stay the same.

Any comment or addition before I finalize my negotiations?

 

[Marasmus1]

Just to pile on— having 0.1 FTE set aside for ‘academic time’ is a joke. You will just spend that finishing notes. They are basically paying you less for a full time clinical load and have no desire to provide any way that’s meaningful for you to advance in terms of teaching/mentoring etc. You aren’t doing research with 0.1 FTE, unless you are doing it on your own weekends/evenings.

I do agree with that. But as per visa waiver job, I do have to provide no less than 40 clinical hours of patient care. So they don`t have much flexibility regarding the academic time

 

[Merovinge]

The offer is revised by the hospital after some back and forth negotiations.

They took the outpatient off the table so at this point this is strictly full time inpatient.

I was able to negotiate down from average 14 patients to strict cap at 12. They won`t start me at 12 and will have me build up from 6 to 12 in 6 months.

Instead of 1:3 weekend coverage, was able to go down to 1:4 weekend coverage with any additional coverage optional and with extra compensation

They also told me that at any point I will either have a resident/fellow or both to help with the load. I would not like to give more than 4 patient to a resident and 6 to a fellow due to educational objective over service but even then I am hoping that it would alleviate some load?

From Average 14 patients to cap at 12 and 1:3 weekends to 1:4 weekends, my overall compensation took some hit from 340k to 310k. The bonus and the other benefits and reimbursements stay the same.

Any comment or addition before I finalize my negotiations?

Adult residents are usually not helpful on CAP inpatient unless you spend a limited amount of time teaching. Usually the time they save you is = or even < then the time spent teaching them and they often come through relatively quickly (4-8 week block).

CAP fellows on the other hand can definitely be time positive (particularly if its a 3 month block or so), they will be more engaged in the work and can do a reasonable job with collateral, notes, etc provided it's a decent program.

Sounds like a very reasonable job to me, pay is very solid per your cap, you get to teach, call is doable. Hope for good therapy and social work support on the IP side but at some point you just need to lock it in and know you can go elsewhere in a few years time. Congrats on the negotiation.

 

[Stagg737]

With private practice, the only advancement I see is buying in the practice or opening your brand new one but unless you create a brand practice like Talkiatry, Amen clinics or Lifestance (which are mostly managed by corporations or like minded people unfortunately) my horizon does not extend further after being an owner or a partner.

Already been said, but those who search for it and are willing to put in the work have almost unlimited opportunities in psych, which is especially true OUTSIDE of academia. Academia seems like it's that much better because paths for advancement can be easily laid out for you. In PP, those opportunities are still there, you just have to be willing to work and make them happen for yourself.

 

[Monocles]

The offer is revised by the hospital after some back and forth negotiations.

They took the outpatient off the table so at this point this is strictly full time inpatient.

I was able to negotiate down from average 14 patients to strict cap at 12. They won`t start me at 12 and will have me build up from 6 to 12 in 6 months.

Instead of 1:3 weekend coverage, was able to go down to 1:4 weekend coverage with any additional coverage optional and with extra compensation

They also told me that at any point I will either have a resident/fellow or both to help with the load. I would not like to give more than 4 patient to a resident and 6 to a fellow due to educational objective over service but even then I am hoping that it would alleviate some load?

From Average 14 patients to cap at 12 and 1:3 weekends to 1:4 weekends, my overall compensation took some hit from 340k to 310k. The bonus and the other benefits and reimbursements stay the same.

Any comment or addition before I finalize my negotiations?

Oof. Should not have taken the salary cut. They took the opportunity to decrease your salary in exchange for very minimal concessions that you could have reasonably justified anyway. You should at least counteroffer for the full 340k and settle for 330k.

Also residents and fellows are not necessarily time-savers. Philosophically the emphasis should be on education so even the best trainees would have you "break even" on time assuming you are genuinely trying to teach. I've seen some really bad residents and fellows that make things infinitely more challenging so be mindful of budgeting your time.

EDIT: nvm saw the VISA part. OP take the deal

 

[Merovinge]

Oof. Should not have taken the salary cut. They took the opportunity to decrease your salary in exchange for very minimal concessions that you could have reasonably justified anyway. You should at least counteroffer for the full 340k and settle for 330k.

Also residents and fellows are not necessarily time-savers. Philosophically the emphasis should be on education so even the best trainees would have you "break even" on time assuming you are genuinely trying to teach. I've seen some really bad residents and fellows that make things infinitely more challenging so be mindful of budgeting your time.

You can try, but this is a really reasonable for a visa job. There's something to be said about having your hard line but also not over-negotiating, particularly if you are not in a position of power (aka us citizen w/ multiple other offers in hand).

 

[Monocles]

You can try, but this is a really reasonable for a visa job. There's something to be said about having your hard line but also not over-negotiating, particularly if you are not in a position of power (aka us citizen w/ multiple other offers in hand).

Ah, I missed the part where OP needed a VISA sponsor. Fair enough.

 

[MedMan80]

Very reasonable gig for j1 waiver, especially if in a decently populated area.