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It makes sense. This brings an important and timely question tho: What attracts people to these horrible w2 contracts offered by big box shops?
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outpatient practice
Started by psychhog
It makes sense. This brings an important and timely question tho: What attracts people to these horrible w2 contracts offered by big box shops?
I think there's more than one trend here bringing salaries down. You're definitely right, the work culture has shifted to minimize additional roles and to get your decent paycheck and live a life outside of medicine. I don't think, however, that psych got more competitive and full of academic types that don't care about salary. I think there was a very brief period where psych got relatively competitive but overall we open more residencies than any other specialty and have very low quality programs opening up every year. The market is just becoming very saturated, not just with NPs but with MD/DOs too. And you're right, once people start signing on for offers that previously no one would take, the market is incentivized to not reward the rest of us anymore. For example, pure inpatient roles have become hard to come by, with more employers requiring outpatient work on top of inpatient -- they know they can fill these slots easier now in large metropolitan areas. Similarly, contract work is becoming lower pay in my area, where previously we had a very tough time recruiting docs, it's now much easier because the more industrious ones do want higher pay. The market gets squeezed though, and thus our pay rates decline because spots are easier to fill in my area.
This is what terrifies me; the oversaturation by both new grads and the artificial increase in supply by non-docs. It makes me want to jump ship to another specialty with infinite, never-ending demand (DR), which would give me strong leverage and freedom.
I love psychiatry, but I love my work/my time being valued appropriately and maximizing my autonomy more. I honestly don't see this process getting any better in the next 5-10 years. This market is the only thing that makes me somewhat regret choosing this field.
My other option is to build a private practice (I'm not keen on it though, especially fresh out), which will allow me to get what I want. I would be focusing on the market of patients that actually value my expertise, unlike these employers treating us like interchangeable widgets (it's absolutely infuriating). However, it'll take many years before I can actually reach my preferred destination, and I'm just not the entrepreneurial type. I may be forced into it, sooner rather than later at this rate.
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I don't think a specialty like this exists. The "good" specialties come and go over time.
You really think DR is going to become cyclical again? The current system is resulting in runaway growth of imaging. I don't see that changing unless the system itself changes appreciably (eg significant decrease in patient volume, complexity, litigiousness, elimination of midlevels in the US)
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DRs definitely do have high compensation compared to the other specialties, but I'm not sure they get a lot of "leverage and freedom." They have to read and interpret a way higher volume of reads today compared to the past because of the downtrending CMS reimbursements And the "complexity" of their reads doesn't really scale commensurately with the reimbursements. just go over to the radiology subforums and read the discussions right now about shoddy reads and the radiologists commenting on how the dynamics play out with regard to high-volume reading demands, etc.
Yeah, I read their forums religiously lol. What you said about volume and complexity is true.
When I say leverage and freedom, I'm talking about ability to have multiple good to high quality offers that you could use to negotiate for better conditions (along with ability to switch to a new good quality job if your current job goes south). That doesn't exist in psychiatry anymore because of the current market.
I mean, it does. You just have to know where to look for the actual good job offers. That won’t necessarily help your negotiations though if the company feels they could hire someone else for a lower rate (ie, excess in supply).
That said, idk that what you’re describing is going to exist in DR for long if it still does. Rads seems to be one of the prime targets for AI implementation in healthcare and the goal/expectation will become AI reads the imaging and a radiologist signs off on hundreds per hour. Or at least this is what healthcare admins want to happen from the couple I’ve talked to about it.
I hope to talk you off the ledge fam. Good jobs are still out there. You can't just walk in with a pulse and get them though. Just a few ounces of targeted effort and you can still get the good jobs in psych. There's just more people willing to accept junk these days, but there were always people out there accepting junk.
That's reassuring, thank you. I'm willing to do anything to secure the future that I want (I'm a hustler), so I hope that's enough.
My plan right now is to start looking again a year out from graduation by posting in the FB groups and cold calling/emailing in the area I want to land in. I'm targeting PP only.
I hope you're right regarding the bolded.
Every radiologist that has deep expertise with ML/AI says that this is totally unrealistic, and that logistically, AI will help more with prioritizing reads by acuity. As far as efficiency, the numbers I hear are around a possible 10% increase in efficiency, which is still not enough to even approach the ever-expanding demand. Furthermore, regulatory hurdles in medicine make widespread adoption relatively slow.
I think the future is very bright for them, at least for the length of my career.
I know it’s true. Not only do I get excessive job postings which do include the occasional hidden gem. I personally know co-residents who are finding solid positions and still have friends/colleagues occasionally try and pull me away from my current job.
Get a strong reputation as a hard worker in residency and put some leg work in and the positions are still out there. They may not check every box you desire (money, schedule, geography, position type, etc), but if you’re at least somewhat flexible they definitely exist.
Fully agree, there are decent jobs out there. It's more the trend that is concerning, and the dwindling job security, where the position you get might not be there at the end of your contract anymore (or be radically changed for the worse). As a young and single psychiatrist I wouldn't mind moving around for good jobs but with a family, having already compromised on geography and practice setting, the fact that several of us at my job are to be laid off due to excess supply (at a job setting where this never previously happened) is concerning. I can only see that getting worse with a job market getting squeezed left and right. Again, I'm not going to starve, I'm better off than most of the country, but it is a trend in our field and it definitely is concerning for the future IMO.
The real major difference is that midlevels basically don't exist in radiology.
It's not AI that's problematic in psych right now, in short it's midlevels and PE firms.
Couldn't agree more. That's why I'm frantically doing everything in my power to find ways to secure my professional and financial freedom, especially in the medium to long term.
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True, but mid levels have been a “threat” in psychiatry for 20+ years. They got FPA in my state around 6 years ago and there is no appreciable difference. On the other hand, PE is a far greater problem. They’re the vehicle that has created both over saturation and under compensation along with promoting laziness and poor care by physicians (and midlevels). I’d also bet pretty much anything that if PE could figure out how to completely replace us with AI they would do it in a heartbeat without a second thought.
Got back this week after 2 weeks off work, the break was nice but I found myself getting anxious about returning to work, worried about how many messages were going to be in my inbox daily which I had to respond to each day while I was off. Get back and am averaging 24-27 patients on my schedule for this week and next week at least. I'm getting crushed. I'm at the point where I'm really considering leaving and opening my own shop so I can have more control over my schedule, work flow, the patients I see etc. I've started reading through sushirolls thread about opening own practice and it has a lot of good info but I've only gotten to the 2nd page so far lol. Anyone else who's opened their own practice care to share some insight? Do you feel you have better control over your day to day schedule and work/life balance?
Skip ahead a bit, Clause and Jules start posting their numbers for their clinic on page 6. Trophyhusband starts posting numbers on page 7. There's a lot of great information in terms of questions and how to run the clinic before that.
Also kind of wild that Sushi was trying to do all of that during the height of COVID. Can't imagine that was helpful at all for a new in-person clinic!
I left employment a few months back. There is no doubt you have more control over your schedule. I'm in a relatively "saturated" area with multiple academic institutions and plenty of self-proclaimed-expert NPs running around, but I've had zero difficulty getting patients (taking a few payers). Your desired practice style, specialty, patient population, surrounding area, and financial needs will determine how easy it is to start up. If you're ok to take insurance, and do a modicum of marketing, you will fill very quickly. Assuming your current employer takes insurance, you will probably have a decent number of folks follow you, too. There are a lot of little things to figure out along the way, but it's not particularly difficult. If you do cash/OON, it's even simpler logistically, but patient acquisition will be harder - you will need to do more marketing/networking and likely find a niche. What sort of questions do you have? What's the fear in leaving a job that is burning you out? By the way, I have no idea how you're managing that many patients a day, sounds awful!
I think it's just more the fear of taking on responsibility of my own clinic. I've never been one that felt I needed complete control of things but the past few years have really highlighted how out of control my schedule feels, how much work is taking over my mental energy even when I'm off, on weekends, or on vacation and don't feel I'm being present with my family enough, worry about income and will I be able to make anywhere close to what I am making now, just those kinds of thoughts. I think I'm at the point that leaving this job is inevitable though. 20+ patients daily with 20 min follow up appointments, supervising NP's and having to send in all controlled meds from their patients when they are also seeing 20+ patients daily is just ridiculous. I live in a top 10 city population-wise in the south and I'm pretty sure most every psych practice around here including ours, is completely booked up and an abundance of patients having difficulty getting in to see someone so I don't really think it will be difficult to fill up with some marketing. I think it's just more the worry about the business/admin side of things since I don't really have much experience at all with that.
With SDN and AI it's never been easier to run your own clinic. There is also the intermediate step (which I am doing) of joining an existing MD only practice. They will cover all your overhead, ideally market and get you patients (you will need to do some of this), and will take then a cut of your revenue. Plenty of ways to still be your own boss and do your own thing.
I probably need to go through all of sushirolls thread (still working on that) but other question would be just the logistics of starting off, location/building/rent/lease, do you start with small business loan and how to go about that, I've seen some things regarding marketing like psychologytoday, visiting primary care docs, therapist, insurance etc. Seems a little daunting at first but not as daunting as continuing with my current gig for long term...
Sort of depends on what you want to do. If you just want to do general psychiatry as a solo doc and take a couple insurances, there's no way you need a business loan. That said, you need to have some savings to live off of for a few months (sounds like you've been making a lot of money, so I'm guessing you do). My advice, assuming you want to do some tele and can work at home, would be to sublease an office 1-2 days a week to keep costs low. Marketing if you take insurance will be pretty easy - you really only need a few therapists/pcps, psychologytoday, and the insurance directories - you'll have more referrals than you can handle, well maybe not you if you're used to that crazy volume at your current gig!
As an aside, I think using Headway or Alma while you are getting your own contracts in place and figuring out the logistics of billing is a decent strategy. The business side you can make needlessly complex. I run as a sole proprietor, as an LLC doesn't protect you from malpractice risk. But a single member LLC is just a quick form you can submit online to your state if you want to do that. In general, I think the key is to just get in the game and you'll start figuring things out/processes that work for you.
Additionally, if you are very open to leaving your job, you can figure out what (if any) conditions would allow you to stay. Ask for those things and see what happens. Willingness to leave is the ultimate leverage. This place seems very dependent on you - you're seeing a ton of patients and overseeing multiple NPs and holding the bag on a lot of controlled substance rx's. Not many psychiatrists would take that job and you're making them A LOT of money that will disappear if you go.
Just to add to what I wrote above, as an outsider, your schedule seems untenable to practice standard of care level psychiatry. And the pay you're receiving is high, but is coming at a very high cost if the stress is intruding into your family time/off time. It also seems risky to see a bunch of 15-20 min follow ups, unless every case is straight forward - you accrue a lot of risk seeing that many patients and being responsible for that many NP patients, too. As we all gain experience, we recalibrate our priorities. And earning as an attending for several years also devalues the monetary aspect a bit. In any case, the income side is pretty much whatever you want it to be in PP, which goes hand-in-hand with being in control of your schedule/WLB.
