Please Critique (Roast?) My Job

[BACyeahyouknowme]

Advertisement - Members don't see this ad

This is a throwaway so as to preserve a little anonymity...

I am a relatively new attending, and I have always appreciated the wisdom on this forum. I'd love some feedback on my job.
It's in the midwest, in a town of 30K people. A beautiful part of the country that people come to for vacations. Lots of outdoor recreation. Nice people, solid schools. In other words, a very decent place to live and raise a family, and a low cost of living to boot.

The job is at a for-profit hospital system. I'm making 250K base for 4600 RVUs, bonus of 56/RVU after that threshold. 60k (15k/year x 4 years) loan repayment, 10K quality bonus (easy to achieve). 25 days of vacation, 5 days CME, 4K CME money. Mainly outpatient, I could easily add in some inpatient if I wanted. Very strong outpatient support staff (friendly, highly-experienced...the kind of place where your outpatient practice can turn into a well-oiled machine). The expectation is for 40 hours a week, without a lot of restriction beyond that--(i.e., schedule however you want, as long as you're producing RVUs. 15/20/30 minute follow-ups, 60/90 minute new evals, balance admin time and clinical time however you need to, as long as you mind the RVUs...starting to see a pattern?)

Home call about one weekday per week (admissions by telephone, from 0-3 phone calls per night), and one weekend per month (round on 20 inpatients, splitting the work with a mid-level--so physically see 10 patients, and then involvement in the other 10 based on the degree of collaboration you want to do). On call days, expectation for hospital consultations after clinic (usually 0-1, rarely 2).

The patients tend to be wonderful, but the region is limited in its resources. No neuromodulation, IOP/PHP, limited access to therapists, and when you can get someone into one, it's probably not the evidence-based kind of therapy to match their problem. Very limited inpatient beds. Weak, struggling CMH system. In short, not much here as far as resources.

I have a wife and two school-age kids. My wife works in our town and can't easily re-locate. We have family in this city. This hospital is the only game in town. I essentially have to work this job or switch to tele-health or some kind of 1099 road warrior lifestyle where I leave for a week or so a month and return home. It's not realistic for me to uproot my family and go somewhere else at this point.

What have you guys seen offered for comparable jobs in the midwest? Based on this hospital system's penny-pinching behavior, I suspect I could do a lot better elsewhere. I'm just not sure how much better.

And as I type this, I'm seeing that my secondary question is--have any of you been stuck in a position like this? So-so job in a location that's hard to leave. How did you personally make it tenable?

 

[Merovinge]

I have a few points.

First, it really is doable to move if you wanted to. You can absolutely prioritize being close to family, SO's job and that's great if that's what is important to you, but that is coming at a cost. The hospital system absolutely knows they are the only gig in town and will treat you accordingly. They have zero incentive to give in to you. I worked in a similar setup for a few years and the hospital absolutely threw its weight around. Turns out hospital execs making $750k/year with limited training in a low CoL area can feel pretty entitled.

Second, I think you make it tenable by recognizing that it provides you the things above (e.g. living where you want to live) while also allowing you to see patients in-person. Tele all day seems terrible to me, despite the growing number of docs who do or like this work. If they let you bill 99214 w/ add on psychotherapy codes, you can also work to have high RVUs and get a substantial bonus that will the job pay reasonably. I know of one psychiatrist that interviewed at my last rural job and ended up taking a job in rural Kentucky for 350k/year with a few bonuses and no-call. Another one in a rural area made low 300's with no call. Those were both jobs taken 2 years ago, I presume the market has moved up a little due to inflation.

Lastly, the job really doesn't sound that bad. You are getting paid less than market for a rural location, but it's hard to know just how desirable this location is. If it's as great as you say, then some of that rural premium likely goes away. The call is annoying but sounds manageable, you clearly are not getting paid for it and I am also sure they would not be open to negotiating on it. I would see if there is a single area that you would like to be different to negotiate, but understand that the VP or CMO or CFO that is negotiating absolutely knows your family situation in a town that size.

 

[BACyeahyouknowme]

I have a few points.

First, it really is doable to move if you wanted to. You can absolutely prioritize being close to family, SO's job and that's great if that's what is important to you, but that is coming at a cost. The hospital system absolutely knows they are the only gig in town and will treat you accordingly. They have zero incentive to give in to you. I worked in a similar setup for a few years and the hospital absolutely threw its weight around. Turns out hospital execs making $750k/year with limited training in a low CoL area can feel pretty entitled.

Second, I think you make it tenable by recognizing that it provides you the things above (e.g. living where you want to live) while also allowing you to see patients in-person. Tele all day seems terrible to me, despite the growing number of docs who do or like this work. If they let you bill 99214 w/ add on psychotherapy codes, you can also work to have high RVUs and get a substantial bonus that will the job pay reasonably. I know of one psychiatrist that interviewed at my last rural job and ended up taking a job in rural Kentucky for 350k/year with a few bonuses and no-call. Another one in a rural area made low 300's with no call. Those were both jobs taken 2 years ago, I presume the market has moved up a little due to inflation.

Lastly, the job really doesn't sound that bad. You are getting paid less than market for a rural location, but it's hard to know just how desirable this location is. If it's as great as you say, then some of that rural premium likely goes away. The call is annoying but sounds manageable, you clearly are not getting paid for it and I am also sure they would not be open to negotiating on it. I would see if there is a single area that you would like to be different to negotiate, but understand that the VP or CMO or CFO that is negotiating absolutely knows your family situation in a town that size.

Thank you, this is exactly the type of perspective I was hoping to get. I realize that this organization is incentivized to pay as little as they can reasonably get away with. I also realize all of the offers I'm hearing about from friends just graduating residency are to be taken with a huge grain of salt unless I can see the contract in black and white, and fully understand their practice environment. Without that, it's easy to imagine everybody else has an amazing contract...

Probably the most realistic approach is to use the autonomy they afford me to maximize what I've got here, assuming compensation is within the realm of reasonable (even if on the low end).

Did you leave your rural job for personal or professional reasons?

 

[Merovinge]

Thank you, this is exactly the type of perspective I was hoping to get. I realize that this organization is incentivized to pay as little as they can reasonably get away with. I also realize all of the offers I'm hearing about from friends just graduating residency are to be taken with a huge grain of salt unless I can see the contract in black and white, and fully understand their practice environment. Without that, it's easy to imagine everybody else has an amazing contract...

Probably the most realistic approach is to use the autonomy they afford me to maximize what I've got here, assuming compensation is within the realm of reasonable (even if on the low end).

Did you leave your rural job for personal or professional reasons?

I left for both reasons. We were never planning on staying at that location, did it exclusively for my wife's visa. That said, even if I liked the area, I would not have stayed with that job. They did exactly what you experience, paying relatively poorly, little to no rural premium, bad call schedule (for psych), they had no competitors so why move on anything. To be able to go to a city and get a pay raise was the biggest no brainer for myself. The people I saw that stayed on at my rural hospital had significant ties to the area and wanted that lifestyle for their families. There's absolutely nothing wrong with that, we are all so blessed to be able to decide where we want to work while still being in the top 1-3% in income.

 

[calvnandhobbs68]

This isn't the most terrible setup I've ever heard of. Merovinge has some great points.

One big thing, are they letting you use the new wRVU schedule to calculate RVUs? If so, that's not that bad, just back of the napkin, 4600/1.92 (wRVU for 99214 now) = 2396 encounters/47 weeks (5 weeks of vacation)= 51 encounters/week = 10ish encounters a day to meet base RVUs. That's totally disregarding 90833s which are worth 1.5 wRVU and will balance out the 99213s you have. 40 patient contact hours a week should easily get you over that.
Bonus is alright too again if they're letting you use the newer wRVU conversion. 56/rvu comes out to 107.5 for a 99214 and 191.5 for 99214+90833.
Decent amount of vacation although in real life "vacation time" is just cutting into your ability to generate extra RVUs depending on how much money you're looking to make.
The call part is where you're getting screwed as there's plenty of jobs similar to this that have absolutely no call whatsoever (along with the consults after clinic thing, yuck). Big thing I would push is at least getting something for the call....does it at least count towards your RVUs for the year? You're basically just making them thousands of dollars for free on the weekend, so if they won't budge on the call requirement, I'd at least get paid something for it.

Yeah, negotiating would come down to how willing are you to walk away? Like merovinge said, I suspect they know they're the game in town and unless you're willing to move, you don't have a good alternative.

 

[TexasPhysician]

I’d call it fine without the weekday call and weekend rounding. With those, you are minimum $50k short of where you should be.

 

[Candidate2017]

This required call schedule of consults and weekend inpatient sounds fine. For a resident.

Clinic pay is meh. It seems rural hospitals play ball only if they're trying to get you to relocate there. But you're already there and have no leverage. Also, rural + poor resources + limited CMHC means the hospital clinic will be the de facto CMHC. So no show rates may be high, cutting into your RVUs.

Though, this is the pandemic/post-pandemic age of telepsych so there is no reason to feel limited geographically. And if you take this job, I wouldn't be surprised to find out the hospital clinic has or will hire a couple of telepsych doctors and pay them (or the locums company) more than you, with no call.

 

[Stagg737]

It's in the midwest, in a town of 30K people. A beautiful part of the country that people come to for vacations. Lots of outdoor recreation. Nice people, solid schools. In other words, a very decent place to live and raise a family, and a low cost of living to boot.

How rural/desirable is this actually? Are we talking somewhere like Lake Geneva, WI that's <90 from 3 major metros or are we talking somewhere that's in the middle of nowhere like Branson that's 4 hours away from anywhere? Also, how long was this position open/how difficult is it to fill? Just getting a feel for how much you're actually being low-balled.

Lots of good insight above. Also a new attending, but some comments based on some of the postings I've been sent and a few jobs I looked into more seriously (examples in following posts)...

With loan repayment and "easy" quality bonus your base for 4 years is basically $275k which isn't terrible, but is low. I looked at several outpatient positions (less seriously) that had a base of $300k+, several included additional sign-on bonuses or loan repayment, a couple of which were within an hour of major metros. Truly rural positions in the midwest were usually a little higher, closer to $350k and/or had significant additional pay ($50k sign-on bonuses, $100-150k loan repayment, etc), though they were clearly less desirable areas. 4600 RVUs also seems a little high, but not unreasonably so. Same with the 56/RVU, little low but not bad.

I wouldn't accept that on-call schedule without either significantly more base salary or pay for call. The schedule itself isn't awful, but without being compensated? Hard pass. For this position I'd expect to be compensated for call and have the RVUs to go towards my total. Also, who gets the RVUs the NP bills? Supervising an NP is just added liability on your license, either make sure you're adequately compensated or don't do it.

The pros I see are the supposedly solid clinical staff and flexibility of schedule which can make lower pay a lot more tolerable, and it sounds like the employer knows that. Personally, I'd demand significant compensation for NP supervision and either require compensation for call shifts, higher base salary, or decrease the RVUs required to hit the bonus (if lowered to 4000/yr it adds $33k to your salary from that 4600). Overall I wouldn't take this position without negotiating and I certainly wouldn't have let them know I was locked into the location while doing it.

 

[Stagg737]

All of the below jobs were sent to be by recruiters, a couple of them were sent multiple times. These are the outpatient jobs in the midwest that listed salaries, most of which I've received in the past 3-4 months.

Spoiler: Job 1: $325k near Kansas City

I got several e-mails on the below job over the course of 6 months. 45 minutes outside a metro of ~500k. An e-mail 2 months earlier advertised a salary of $300k with $150k of student loan forgiveness. A co-resident a year younger than me ended up signing on as a PGY-3 for less than what was offered in the previous e-mail.

• Open to inpatient or outpatient or combo of both. Mayo affliated, Top 1% Hospital.
• Starting base salary 325K
• 50K Sign On, 150-200K guaranteed student loan assistance
• Top 1% hospital and affiliated with Mayo Clinic
• Opportunity for all Inpatient OR all Outpatient or mix of both
• ECT training would be a plus but not a must
• Very flexible schedule, 8 hours per day
• Hospital located 40 minutes North of Kansas City and airport
• Clinic located across from Hospital
• Flexibility, Teamwork and supportive organization are huge selling points

Spoiler: Job 2: $250-275k in downtown Chicago

"An FQHC just off Lakeshore Drive, in downtown Chicago, that is committed to eliminating health disparities and improving the lives of LGBTQ people is in search of a consult-liaison Psychiatrist to join their passionate and mission-driven team. This is a great organization that supports individuals' success, celebrates diversity & racial equity, and is on the cutting-edge of LGBTQ care!"

Practice/Job Description

• Support the integrated care team—primary care provider, patient, and therapists through regular consultation on an assigned caseload of patients
• Advise primary care providers on appropriate medications and other treatment strategies
• Provide care team with educational support on diagnosing and managing behavioral health conditions
• Diagnose and treat patients with mental, emotional, substance use and behavioral disorders in an interdisciplinary, integrated care setting
• Participate in programmatic design of integrated health systems and offer guidance in the integration of psychiatry
• Progressive & collaborative environment that offers challenging and rewarding work with complex populations

Compensation & Benefits

• $250k-$270k base salary range
• Employer-sponsored health, dental, vision insurance
• 401k program with up to 5% employer match
• 4-weeks time off, 9 paid holidays & 12 sick days
• Student loan forgiveness & tuition reimbursement programs
• CME time off/allowance

Spoiler: Job 3: $340-350k in Burlington, IA

"I want to share some information about a 380-bed independent, regional, financially stable health system is actively recruiting for a Geriatric and Adult Psychiatrist in SE Iowa."

Adult is an inpatient or outpatient position and Adult or Child is outpatient
Starting salary is $340-350K base
50K sign on bonus plus full benefits
7 weeks PTO
Over 140 providers on staff and 2300+ employees
Rated as a "Top Workplace" in Iowa by the Des Moines Register!
Production based compensation model enables you to be on equal footing with your partners from day one

A vibrant, safe and charming riverfront community with excellent public and private educational and recreational options for families.
An easy drive to Chicago and St. Louis and 1hr drive to University of Iowa in Iowa City. Daily flights to both St. Louis and Chicago and Amtrak to Chicago.

Spoiler: The subject of this e-mail was "300K Salary Generous Sign-on Bonus in Springfield, IL - Adult Psychiatry"

"I hope you're doing well! I want to share some information about a position that we have with a long running practice in Springfield, IL. Join a team of 5 Psychiatrists and 5 NPs with a flexible mix of inpatient and outpatient coverage plus the opportunity to perform ECT. Existing affiliation with SIU provides additional teaching opportunities."

• Adult Psychiatry
• No addiction, dementia, or Medicaid patients
• Support: Nurses, MAs, prior auth. team, and coding specialists
• 1:6 weekend call, practice patients only
• Benefits: 40-days PTO, Student Loan Repayment, 401k match, and more

 

[BiscoDisco]

Have you considered doing your own practice out of curiosity?

 

[Sushirolls]

And as I type this, I'm seeing that my secondary question is--have any of you been stuck in a position like this? So-so job in a location that's hard to leave. How did you personally make it tenable?

Yep. I opened my own practice.

 

[Sushirolls]

I’d call it fine without the weekday call and weekend rounding. With those, you are minimum $50k short of where you should be.

The wRVUs from the inpatient weekend will be enough to propel into the wRVU "bonus" or allow 1-2 non-clinic days per month, off days, to 'compensate' for those extra working days. Or he could work more 9-3PM and be able to drop off pick up the kids from daycare.

 

[AD04]

Numbers are less competitive than median.

You need to have a better offer and be willing to take it. Since you're geographically limited and you want to be near family, telepsychiatry is the best bet. Then once you have the better offer on hand, you can go back to your employer to re-negotiate or take the better offer.

If you look hard enough, you can get a job which can cover your current family income. Then your wife wouldn't have to work and may be more flexible geographically.

 

[MedMan80]

I'm in a rural area with 30 min f/u and 1hr new evals. With no-shows and using my CME/Vac time liberally i am barely cracking 30th %'ile and so not really eligible for RVU bonuses... if the place is well oiled like you say, you should have better luck than me.

The base still sounds low to me, 250 to start was the rate 7-8 years ago. I would want closer to 280-300 base.

 

[BACyeahyouknowme]

This isn't the most terrible setup I've ever heard of. Merovinge has some great points.

One big thing, are they letting you use the new wRVU schedule to calculate RVUs? If so, that's not that bad, just back of the napkin, 4600/1.92 (wRVU for 99214 now) = 2396 encounters/47 weeks (5 weeks of vacation)= 51 encounters/week = 10ish encounters a day to meet base RVUs. That's totally disregarding 90833s which are worth 1.5 wRVU and will balance out the 99213s you have. 40 patient contact hours a week should easily get you over that.
Bonus is alright too again if they're letting you use the newer wRVU conversion. 56/rvu comes out to 107.5 for a 99214 and 191.5 for 99214+90833.
Decent amount of vacation although in real life "vacation time" is just cutting into your ability to generate extra RVUs depending on how much money you're looking to make.
The call part is where you're getting screwed as there's plenty of jobs similar to this that have absolutely no call whatsoever (along with the consults after clinic thing, yuck). Big thing I would push is at least getting something for the call....does it at least count towards your RVUs for the year? You're basically just making them thousands of dollars for free on the weekend, so if they won't budge on the call requirement, I'd at least get paid something for it.

Yeah, negotiating would come down to how willing are you to walk away? Like merovinge said, I suspect they know they're the game in town and unless you're willing to move, you don't have a good alternative.

Thank you for your thoughts. Still using the old schedule for RVUs, unfortunately. Call is compensated in that I see and bill for mid-level patients in the hospital as well as my own, and obviously generate RVUs for the consults.

As far as being willing to walk, insightful replies like I’m getting here are helping me to weigh the pros and cons. It’s a good setup for my family. The more exploited I feel, the more I’m willing to do tele-psych or traveling 1099 work. A tale as old as time…

 

[BACyeahyouknowme]

I'm in a rural area with 30 min f/u and 1hr new evals. With no-shows and using my CME/Vac time liberally i am barely cracking 30th %'ile and so not really eligible for RVU bonuses... if the place is well oiled like you say, you should have better luck than me.

The base still sounds low to me, 250 to start was the rate 7-8 years ago. I would want closer to 280-300 base.

Thank you for your thoughts. So far, almost everyone is showing. I think people are grateful for the service I provide (maybe just a narcissist fantasy?). Probably 80% of my visits include 90833, so I’m pretty productive thus far.

Base sounded low to me! Feels low, too. Trying to make a case for or against just grinning and bearing it for my family.

 

[BACyeahyouknowme]

Numbers are less competitive than median.

You need to have a better offer and be willing to take it. Since you're geographically limited and you want to be near family, telepsychiatry is the best bet. Then once you have the better offer on hand, you can go back to your employer to re-negotiate or take the better offer.

If you look hard enough, you can get a job which can cover your current family income. Then your wife wouldn't have to work and may be more flexible geographically.

Thank you, that’s a very reasonable option. Frankly, with her working we could even swing me moving to part-time. She makes a lot of money.

 

[BACyeahyouknowme]

Yep. I opened my own practice.

Smart.

Have you considered doing your own practice out of curiosity?

Absolutely. That’s obviously a whole other kettle of fish, and I don’t think I’m a great businessman, but who knows? All my friends who have done it say they’d never go back to working for the Man. Might be one of the better alternatives here.

 

[BACyeahyouknowme]

How rural/desirable is this actually? Are we talking somewhere like Lake Geneva, WI that's <90 from 3 major metros or are we talking somewhere that's in the middle of nowhere like Branson that's 4 hours away from anywhere? Also, how long was this position open/how difficult is it to fill? Just getting a feel for how much you're actually being low-balled.

Lots of good insight above. Also a new attending, but some comments based on some of the postings I've been sent and a few jobs I looked into more seriously (examples in following posts)...

With loan repayment and "easy" quality bonus your base for 4 years is basically $275k which isn't terrible, but is low. I looked at several outpatient positions (less seriously) that had a base of $300k+, several included additional sign-on bonuses or loan repayment, a couple of which were within an hour of major metros. Truly rural positions in the midwest were usually a little higher, closer to $350k and/or had significant additional pay ($50k sign-on bonuses, $100-150k loan repayment, etc), though they were clearly less desirable areas. 4600 RVUs also seems a little high, but not unreasonably so. Same with the 56/RVU, little low but not bad.

I wouldn't accept that on-call schedule without either significantly more base salary or pay for call. The schedule itself isn't awful, but without being compensated? Hard pass. For this position I'd expect to be compensated for call and have the RVUs to go towards my total. Also, who gets the RVUs the NP bills? Supervising an NP is just added liability on your license, either make sure you're adequately compensated or don't do it.

The pros I see are the supposedly solid clinical staff and flexibility of schedule which can make lower pay a lot more tolerable, and it sounds like the employer knows that. Personally, I'd demand significant compensation for NP supervision and either require compensation for call shifts, higher base salary, or decrease the RVUs required to hit the bonus (if lowered to 4000/yr it adds $33k to your salary from that 4600). Overall I wouldn't take this position without negotiating and I certainly wouldn't have let them know I was locked into the location while doing it.

Thanks. It’s more like Branson. World-class area for a certain type of outdoor activity, but several hours from anywhere with decent sushi or a museum. The positions are extremely hard to fill, because most people are only here for family ties (I guess I am only here for that, too).

I get all the mid-level RVUs and call-related consult RVUs, but nothing extra for getting phone calls at night.

Sadly, this WAS with negotiating. Offer was even worse than before.

Appreciate your thoughts, very similar to my sense of current rural offers in my area.

I think the summary from all of these extremely helpful comments is that I’m getting hosed, and it will be up to me to use my flexibility to make it worth it or abandon ship for PP/tele-psych land. Or just accept the mediocrity of the position for the benefit of my family, I suppose.

 

[smalltownpsych]

I vote for private practice, but then again that’s what I just opened up so I’m seeing it through my own narcissistic lens.😊
Being on-call is the worst part of that job in my mind. I still get a stress response when I hear the ring tone on a tv show that was the same as the ring I used for the four years where I was taking call. In private practice, I am sort of on call but it’s only for my actual patients, much different than covering for a rural hospital. I also don’t know if I like that 40 hour expectation. Does that mean if you’re afternoon schedule falls apart you can’t leave to enjoy that outdoor acti ity that brings people to the area. Also, a big point in my mind is whether or not you enjoy that activity that brings people to the town. I live in a rural resort town myself and I shudder to think of the offer that I got for Wichita KS once. Student loan payments can always be deferred, but I gotta ski!

 

[calvnandhobbs68]

Thank you for your thoughts. Still using the old schedule for RVUs, unfortunately. Call is compensated in that I see and bill for mid-level patients in the hospital as well as my own, and obviously generate RVUs for the consults.

As far as being willing to walk, insightful replies like I’m getting here are helping me to weigh the pros and cons. It’s a good setup for my family. The more exploited I feel, the more I’m willing to do tele-psych or traveling 1099 work. A tale as old as time…

Yeah old RVU conversion makes this much less favorable. That's lame.

 

[Merovinge]

Thanks. It’s more like Branson. World-class area for a certain type of outdoor activity, but several hours from anywhere with decent sushi or a museum. The positions are extremely hard to fill, because most people are only here for family ties (I guess I am only here for that, too).

I get all the mid-level RVUs and call-related consult RVUs, but nothing extra for getting phone calls at night.

Sadly, this WAS with negotiating. Offer was even worse than before.

Appreciate your thoughts, very similar to my sense of current rural offers in my area.

I think the summary from all of these extremely helpful comments is that I’m getting hosed, and it will be up to me to use my flexibility to make it worth it or abandon ship for PP/tele-psych land. Or just accept the mediocrity of the position for the benefit of my family, I suppose.

I think you have synthesized the information provided very well. Glad you find the area desirable but it sounds pretty undesirable in general to the current US population. You might think that gives you some leverage but it sounds like tough going with the local monopoly. PP and tele-psych is definitely an option, as is accepting the mediocrity. .Best of luck with whatever you decide.

 

[Stagg737]

Thanks. It’s more like Branson. World-class area for a certain type of outdoor activity, but several hours from anywhere with decent sushi or a museum. The positions are extremely hard to fill, because most people are only here for family ties (I guess I am only here for that, too).

I get all the mid-level RVUs and call-related consult RVUs, but nothing extra for getting phone calls at night.

Sadly, this WAS with negotiating. Offer was even worse than before.

Appreciate your thoughts, very similar to my sense of current rural offers in my area.

I think the summary from all of these extremely helpful comments is that I’m getting hosed, and it will be up to me to use my flexibility to make it worth it or abandon ship for PP/tele-psych land. Or just accept the mediocrity of the position for the benefit of my family, I suppose.

Yikes, what you've got now sounds barely acceptable and that's only if you don't mind the call. Honestly, I wouldn't have taken the position you negotiated for, I probably wouldn't have even responded to the original proposal if it was much worse. If the positions are that hard to fill you should be able to negotiate if you've got some kind of leverage. Honestly, you can find telepsych jobs that pay as well or better for the same amount of daytime work without any call. If there's that great of a need in the area, PP can also be a great option if you can market yourself well and build a practice.

 

[painballer27]

Do you have a non-compete currently?

 

[troutscout]

Smart.

Absolutely. That’s obviously a whole other kettle of fish, and I don’t think I’m a great businessman, but who knows? All my friends who have done it say they’d never go back to working for the Man. Might be one of the better alternatives here.

These are learnable skills! You can always invest in coaching or courses to help you learn them and to set yourself up to succeed in private practice.

It seems that a lot of telepsych positions (particularly those run by start ups etc) are by and large exploitative and pay poorly since so many psychiatrists and physicians in general are looking for these types of jobs.

You can always temporarily work 1099/locums positions as your private practice grows.

Hope you keep it as an option, even if you are in rural Midwest.

 

[whopper]

If you're a new attending you're likely very green and still will be in a steep learning curve if you worked in an academic setting.

A problem with working in rural areas is you're one of the only people that can give help and you have a lack of people to refer out in case you can't handle the case. The bonus of being a rare doctor is you're in demand. The problem is you're the only option. You may need to refer out and can't or the closest hospital with a psych unit could be dozens of miles away.

I had a patient of mine stuck in inpatient in a hospital in a rural area with no psychiatrists. She had no psych care for months.

 

[BACyeahyouknowme]

If you're a new attending you're likely very green and still will be in a steep learning curve if you worked in an academic setting.

A problem with working in rural areas is you're one of the only people that can give help and you have a lack of people to refer out in case you can't handle the case. The bonus of being a rare doctor is you're in demand. The problem is you're the only option. You may need to refer out and can't or the closest hospital with a psych unit could be dozens of miles away.

I had a patient of mine stuck in inpatient in a hospital in a rural area with no psychiatrists. She had no psych care for months.

Thanks, you’ve said it perfectly. I am still green, and frankly never imagined how steep the learning curve into attendinghood would be. In my area, I am it. I’m the expert. No one is coming to save me and there’s nowhere else to refer patients. It’s an added wrinkle to working in the middle of nowhere. Extra stress because I can envision better treatments for my patients, but they will never access them.

 

[Merovinge]

Extra stress because I can envision better treatments for my patients, but they will never access them.

That part will not change with any amount of experience. It's part of the rural psychiatrists life. Just like dealing with parents is part of being a child/adolescent psychiatrist. You can see what virtual PHP/IOP experiences are now available and refer out the occasional case to several hours away, but by in large it's you versus mental illness. Best of luck, it's a fight worth fighting.

 

[Sushirolls]

*It's not just rural. Even in metropolitans their might not be DBT services, or if they exist they have 6+ month waiting lists. Or if PHP/IOP services do exist they aren't quality. I'm in a metro, and my referral list for Neuropsych extends hours away to the next metro. Many of my patients currently have given up on finding therapists.

The resource gap between rural and urban, IMO isn't so wide anymore.

 

[Candidate2017]

Extra stress because I can envision better treatments for my patients, but they will never access them.

Most patients never access the best treatments. Due to their own choice. It's ok to not internalize patient choices or societal resource allocation. Endocrinologists, cardiologists, PCPs don't get stressed 95% of their patients refuse to access superior treatment: diet, exercise, smoking cessation.

There are also way less heme-oncs than psychiatrists, and even less heme-oncs in rural areas. Are there even any rural heme-oncs? Besides making treatment recs and referrals, I don't think rural heme-oncs internalize anxiety that the nearest chemo infusion center or gamma knife is 4-5 hours away.

*It's not just rural. Even in metropolitans their might not be DBT services, or if they exist they have 6+ month waiting lists. Or if PHP/IOP services do exist they aren't quality. I'm in a metro, and my referral list for Neuropsych extends hours away to the next metro. Many of my patients currently have given up on finding therapists.

There's a "shortage" everywhere. The people who can really do something, i.e. "non-profit" hospital CEOs, are more concerned about profits/opening oncology-cardiology-surgical centers, and avoiding things that decrease profits such as mental health. A hospital CEO could make a huge dent in the "shortage" simply by donating a tenth of their income to fund mental health resources.

Even if there were no access issues, arguably, most DBT or PHP places aren't great and their true utility is being a holding environment. And most people who seek psychiatry services generally want a pill and have no interest in doing real therapy.

In my opinion, the drawback of rural is legally being stuck in a relationship with patients you are trying to discharge. The standard of care may require you to write for months of medications, for a patient you are discharging due to non-compliance, threats, or other unpleasant behaviors.