PP or employment?

[bulleface87]

What is the realistic expectation for net compensation through private practice? Do you think it's worth pursuing PP if employed positions are paying 350K+ gross.

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[Sushirolls]

Only you can answer that question.

What are the things that you value?

 

[splik]

In general, private practitioners make similar amounts to those who are employed, though the floor and ceiling tends to be much lower and higher in pp. The primary reason for choosing pp is about having autonomy - include the way you practice, the patients you see, the treatments you provide, the hours you work, the payers you accept (or don't) and your fee schedule. Also you may anticipate that it could take a while to fill your practice (especially if private pay) so your compensation may be lower the first year (or 2 or 3) than employed particularly if your employed compensation is about the 75%ile.

Remember when doing the gross to consider the total compensation - including vacation, sick days, educational days, CME money, retirement/pension contributions, health and dental insurance, disability insurance when comparing things. Often when you add in these benefits, the amount you need to earn in pp to be comparable to employed may be over 400k working full time.

 

[bulleface87]

In general, private practitioners make similar amounts to those who are employed, though the floor and ceiling tends to be much lower and higher in pp. The primary reason for choosing pp is about having autonomy - include the way you practice, the patients you see, the treatments you provide, the hours you work, the payers you accept (or don't) and your fee schedule. Also you may anticipate that it could take a while to fill your practice (especially if private pay) so your compensation may be lower the first year (or 2 or 3) than employed particularly if your employed compensation is about the 75%ile.

Remember when doing the gross to consider the total compensation - including vacation, sick days, educational days, CME money, retirement/pension contributions, health and dental insurance, disability insurance when comparing things. Often when you add in these benefits, the amount you need to earn in pp to be comparable to employed may be over 400k working full time.

I dont see the benefit in opening your own practice if youre paying for an office space, waiting for your panel to fill, just to make 400k in the end. Seems doable nowadays with employed positions alone. I guess autonomy is the only benefit.

 

[bulleface87]

Only you can answer that question.

What are the things that you value?

money

 

[Sushirolls]

PP has greater chance, that is the direction.

 

[Stagg737]

money

In that case inpatient/corrections locums in the morning + PP clinic afternoon is probably the highest ceiling without spending years to build. You can cobble together 2-3 "full-time" positions and hit well over $500k fairly quickly. This will likely require flexibility and some sacrifices with work/life balance, but it's very doable.

 

[finalpsychyear]

In that case inpatient/corrections locums in the morning + PP clinic afternoon is probably the highest ceiling without spending years to build. You can cobble together 2-3 "full-time" positions and hit well over $500k fairly quickly. This will likely require flexibility and some sacrifices with work/life balance, but it's very doable.

For me it was less about just hitting certain numbers but how you get there and being able to maintain it easily. Most young guns just look at the raw numbers. I looked at never working nights, wknds, or holidays and having maximum autonomy and being hard to replace. PP and admin role like med director make a pretty solid combo with some longevity built in.

However, busting tail to hit 400+ as a 1099 is pretty much there for anyone even more if ur willing to do wknds,nights,holidays but hard pass for me.

 

[rjs2131]

Generally speaking - work smarter, not harder for the same $$ —> PP > employment

The best situation IMO is a group PP where you get all of the benefits of an employee while enjoying the higher $/hr and autonomy/flexibility of PP.

Remember - any time you’re an employee, you inherently have to generate enough to keep your employer happy. You also tend to have more admin above you making decisions that may not be ideal for clinical care. Can’t put a $ value on some of these factors and you don’t realize how much they impact job satisfaction until you’re too far in.

How much you make over your career/how you build wealth > how much you make in a year.

 

[Bartelby]

I have worked for employers and in part time private practice. What others say here about autonomy and control of your practice is spot on. I learned that an employer can absolutely change the terms of your employment pretty much unilaterally and you just have to live with it or quit. In my case, that meant piling on a larger caseload plus more administrative duties. While employment is easier (at least in the beginning) and comes with many positives, you do to a large extent turn the power to control your practice over to your employer. From what I have seen, admin or business types use that to slowly or quickly make you do more with less.

When you build the practice it's yours and you have much more say in how you practice, with much lower chances of suddenly having to deal with worse working conditions.

 

[Bartelby]

Your future employer:

 

[mistafab]

Employed gig:
“Dear Cog-in-the-machine,

we have unilaterally decided that you must complete a phq9, Gad7, Audit-C, and c-ssrs on every patient at every visit regardless of diagnosis or chief complaint.

We realize in total this will take almost half an hour to complete. You now must complete all visits in 20 minutes. If you do not meet these metrics, you suck, and your productivity bonus will be decreased, as will your salary. We care about patients and you don’t.

Sincerely,
fearless leaders, MSW ABC, FU POS, LOL FAP”

When you hear PP docs say ‘autonomy’ - this is part of what they mean.

 

[Mad Jack]

Your future employer:

View attachment 379205

Nice thing is, if that happens you can just walk to the next place, or do locums. Demand for us is much higher than supply

 

[Stagg737]

Employed gig:
“Dear Cog-in-the-machine,

we have unilaterally decided that you must complete a phq9, Gad7, Audit-C, and c-ssrs on every patient at every visit regardless of diagnosis or chief complaint.

We realize in total this will take almost half an hour to complete. You now must complete all visits in 20 minutes. If you do not meet these metrics, you suck, and your productivity bonus will be decreased, as will your salary. We care about patients and you don’t.

Sincerely,
fearless leaders, MSW ABC, FU POS, LOL FAP”

When you hear PP docs say ‘autonomy’ - this is part of what they mean.

Or if you're at a VA the annual DV screening/assessment. Plus the annual treatment plan update. And good luck if you have to do a CSRE for any positive Columbia and enter it into CPRS during your appointment. Can't count how many times during my outpatient year I had to stay late filling out completely unnecessary forms into the ancient EMR.

 

[Bartelby]

Nice thing is, if that happens you can just walk to the next place, or do locums. Demand for us is much higher than supply

Very true. That's what I ended up doing, though it was a rough time. You get so used to your team, colleagues and system. It just doesn't sit well though feeling like if the system gets away with the changes they just hoisted on you more changes would keep coming. The thought of working a job that gets worse year after year outweighed the comfort of sticking with what I knew

 

[FlowRate]

The biggest cost to private practice is the financial uncertainty but the benefit is extreme clinical autonomy. If I were to ever go private practice it would be for the related reasons of being super tired of the "I'm pretty sure I have ADHD and ASD and need you to give me Adderall" intakes and the lack of true control over panel size/return rate. But opting out of 25-50% of consumer demand could limit your ability to fill a practice quickly.

 

[Sushirolls]

^I'm in private practice and I'm still seeing that CC. It for sure has limited my practice growth as these people just go get a random MSW to diagnosis and treat their ASD, or they never return, to go find a random ARNP who prescribe them a stim.

 

[FlowRate]

^I'm in private practice and I'm still seeing that CC. It for sure has limited my practice growth as these people just go get a random MSW to diagnosis and treat their ASD, or they never return, to go find a random ARNP who prescribe them a stim.

At least in PP you can choose to do things like phone screening for those CC's, putting info about it on your website, or saying "no" in a way that only reflects on that person's word of mouth about you vs. word of mouth about your organization with subsequent potential engagement with associated institutional complaint mechanisms. Costs and benefits to those actions, of course.

 

[clausewitz2]

At least in PP you can choose to do things like phone screening for those CC's, putting info about it on your website, or saying "no" in a way that only reflects on that person's word of mouth about you vs. word of mouth about your organization with subsequent potential engagement with associated institutional complaint mechanisms. Costs and benefits to those actions, of course.

How often do you really get pressure about this from your organization v the fear of dealing with institutional complain apparati? The couple of agencies/health systems I have worked with have never breathed a peep about me saying no to stimulants or benzos when my documentation was crystal clear as to why I thought they were a bad idea. Is it really still an issue nothwithstanding clearly documented reasoning at your shop?

 

[dl2dp2]

The ceiling is much higher in PP. $350 is not very good honestly by PP standards. If you truly only care about money PP is a vastly superior option. The other thing is the WLB is unparalleled in PP. "Autonomy" really means WLB. What this really means is that dollar per hour of work is much higher PP.

That being said, not everyone can make it work in PP. I have many stories. It's weird. Not exactly sure what it is. This is uncorrelated to real or even perceived clinical skills/prestige, etc. the obvious factors. Getting a 350k facilities job is relatively trivial these days.

 

[finalpsychyear]

The ceiling is much higher in PP. $350 is not very good honestly by PP standards. If you truly only care about money PP is a vastly superior option. The other thing is the WLB is unparalleled in PP. "Autonomy" really means WLB. What this really means is that dollar per hour of work is much higher PP.

That being said, not everyone can make it work in PP. I have many stories. It's weird. Not exactly sure what it is. This is uncorrelated to real or even perceived clinical skills/prestige, etc. the obvious factors. Getting a 350k facilities job is relatively trivial these days.

The gen Z wanted their $$ yesterday. Click click culture. Ain't nobody got time for building a PP or stringing multiple side gigs esp if they blasphemously expect wknd or after 4pm hours as it would totally mess up brunch and happy hour plans. you know...

 

[dl2dp2]

The gen Z want their $$ now. Click click culture. Ain't nobody got time for building a PP or stringing multiple side gigs esp if they blasphemously expect wknd or after 4pm hours.

lol
well, I don't work a lot maybe 15-20 hours a week max. I do work after 4 and a little bit of the weekend. My WLB is quite honestly much better than people who work full-time for a facility, even if they don't work nights and weekends. I go to the gym in the middle of the day 5 days a week. Most of my MD colleagues work way more than I do. This is my 10th year of PP, and things just keep going on the up and up. PP is like the antithesis of stress. In most of my therapy sessions, I feel like I'm doing a guided meditation session for myself because I talk slowly and quietly, and let the patient talk. Or I give a brief lecture on behavioral restructure. It's all very mindful and relaxing. I literally feel LESS stressed after work. It's kind of hilarious. Most of my patients adore me, and I adore most of my patients. Every day I look at my calendar and I go, here are my favorite people! People who don't like me drop out anyway. This is not to say the cases aren't hard. People have very difficult issues, but it feels very easy to me because I've seen it a thousand times and have the right expectations.

I can't imagine working a facilities job can ever get to this point. I've worked at facilities before and it doesn't give you the luxury of being able to polish your craft to a degree that makes you feel like you really are very very very good at what you do for a living. I feel like with every case I'm this really good carpenter who's making this beautiful piece of furniture that looks a little different every time and I'm getting better and better. If I was a hired carpenter I'd imagine that I'd be making the same furniture over and over.

 

[finalpsychyear]

lol
well, I don't work a lot. I do work after 4 and a little bit of the weekend. My WLB is quite honestly much better than people who work full-time for a facility, even if they don't work nights and weekends. I go to the gym in the middle of the day 5 days a week. Most of my MD colleagues work way more than I do. This is my 10th year of PP, and things just keep going on the up and up. PP is like the antithesis of stress. In most of my therapy sessions, I feel like I'm doing a guided meditation session for myself. I literally feel LESS stressed after work. It's kind of hilarious.

I'm sure it took a little bit of extra work to get it up and running at the start. For me, I made less and started working on my PP in 4th year residency and made half what my employed colleagues made in year 1 but i probably have caught up.

Yes I work maybe more than average: 50-55 a week but 40 ish is tele most weeks and sometimes due to holidays or vacations all of it is tele in a week. I also can usually work out 4 times during the work week during business hours (lunch)
Id love to be in position in the next several years that work is optional even though I would still work similar amounts but more time off.

In that scenerio, i have won the game and a new chapter of other endeavors may be explored.

 

[dl2dp2]

I'm sure it took a little bit of extra work to get it up and running at the start. For me, I made less and started working on my PP in 4th year residency and made half what my employed colleagues made in year 1 but i probably have come out ahead several years later.

Yes. I remember the first year or two had a HUGE learning curve. It was quite stressful for a time clinically because I was dealing with unreliable and quite dysfunctional patients with fairly severe personality disorders and substance use issues. There were also issues relating to medical legal, unpaid bills, etc. etc. etc. Relationships with a family are a huge issue that took a number of years to learn.

But as the years go by, you make more money and stress less about all of these things, then the clinical issues become interesting puzzles and the patients become much more human. It becomes let's solve this problem together with this frame, and I know what I am doing and I know I am good at it. There are still things to learn. The field is quite dynamic. But the stress level is way way way down and the pay level is way way way up.

It's also interesting I think because I tend to take sicker patients than other PP docs don't take. So this ends up sharpening my skills quite a bit. I take sicker patients and insist on delivering what I think is the best treatment plan and then charge a huge amount of money for it. But there is also very little inefficiency in that people generally tend to feel the money spent has been worth it. It's been a system that's working well. This is just not a model that a traditional facilities job can incorporate.

My next set of goals is to change what I think is a "premium" product into a truly "luxury" experiential product. I'm not sure exactly what the steps are yet but it's been what's on my mind.

 

[FlowRate]

How often do you really get pressure about this from your organization v the fear of dealing with institutional complain apparati? The couple of agencies/health systems I have worked with have never breathed a peep about me saying no to stimulants or benzos when my documentation was crystal clear as to why I thought they were a bad idea. Is it really still an issue nothwithstanding clearly documented reasoning at your shop?

Good question/point, no one in my chain of command is going to give me crap about saying "no." Which I do on a regular basis. But I am aware that when I say "no" it reflects on the organization ("Kaiser sucks") as a whole in a way that I do care about a little and often generates extra work for the system (transfer intake appointment, complaints, etc.)

 

[comp1]

If it's just money and really nothing else, go do corrections. I seriously doubt you can beat that including benefits with a private practice unless you are in an amazingly high cost of living area and have a spectacular cash only network of referrals to jump into. If for some reason your state's corrections system isn't so overburdened as to offer massive and consistent overtime opportunities, you can always go do your private practice stuff in the evening.

 

[TerraceHouse]

money

I would argue almost as important if not more important decision to make if this is the case is actually: 1) don't buy a house and rent a reasonable priced living space. 2) don't buy a new or luxury car. 3) don't accept a job that'll limit your capability to work elsewhere if you can.

 

[clausewitz2]

lol
well, I don't work a lot maybe 15-20 hours a week max. I do work after 4 and a little bit of the weekend. My WLB is quite honestly much better than people who work full-time for a facility, even if they don't work nights and weekends. I go to the gym in the middle of the day 5 days a week. Most of my MD colleagues work way more than I do. This is my 10th year of PP, and things just keep going on the up and up. PP is like the antithesis of stress. In most of my therapy sessions, I feel like I'm doing a guided meditation session for myself because I talk slowly and quietly, and let the patient talk. Or I give a brief lecture on behavioral restructure. It's all very mindful and relaxing. I literally feel LESS stressed after work. It's kind of hilarious. Most of my patients adore me, and I adore most of my patients. Every day I look at my calendar and I go, here are my favorite people! People who don't like me drop out anyway. This is not to say the cases aren't hard. People have very difficult issues, but it feels very easy to me because I've seen it a thousand times and have the right expectations.

I can't imagine working a facilities job can ever get to this point. I've worked at facilities before and it doesn't give you the luxury of being able to polish your craft to a degree that makes you feel like you really are very very very good at what you do for a living. I feel like with every case I'm this really good carpenter who's making this beautiful piece of furniture that looks a little different every time and I'm getting better and better. If I was a hired carpenter I'd imagine that I'd be making the same furniture over and over.

Very much this. Exactly how much I have enjoyed building a treatment relationship with my long-term patients was a surprise to me. It is a very weird and one-sided relationship but it is a relationship and I think at least if you are successful at it you come to find some aspect of just about anyone who stays in treatment to admire or like. Some days absolutely is a bit like old home week, wondering what such and such is up to and how this thing turned out for wossisname and if you know who managed to actually do the thing, and being really excited to learn the answers.

 

[clozareal]

My next set of goals is to change what I think is a "premium" product into a truly "luxury" experiential product. I'm not sure exactly what the steps are yet but it's been what's on my mind.

My dentist has disposable slippers for each patient when they arrive if they want it, paraffin hand wax, a massage chair, TV on the ceiling with airpod noise cancelling headphones, gives me a lavender face towel after. It's really a luxury dental experience.

 

[comp1]

Massage chair during dental procedures seems...challenging. Seems like kind of a thing where you need the patient to stay still.

 

[Sushirolls]

My next set of goals is to change what I think is a "premium" product into a truly "luxury" experiential product. I'm not sure exactly what the steps are yet but it's been what's on my mind.

My dentist has disposable slippers for each patient when they arrive if they want it, paraffin hand wax, a massage chair, TV on the ceiling with airpod noise cancelling headphones, gives me a lavender face towel after. It's really a luxury dental experience.

My vision of luxury would be this:

Log cabin as office building. Legit wood fireplace in waiting room and office. Add wood to fire mid appointment when necessary. Cigars permissible. Coffee/whiskey bar [*not for certain patients, and make clear, etc]. Deposit area for firearms in foyer. Animal heads everywhere. Animal hides/fur everywhere. Hefty quality wood furniture like Amish or better. Horse hitching post up front on rare chance someone were ever so inclined. Parking spots large enough for diesel trucks, with dual wheels. Include a payment scheme that includes goods/services. I.e. follow up visit could be paid with 30 mature laying hens, 12 months or younger. 6lbs moose meat. 7.5lbs black bear. 3/4 a cord of wood.

Have a 100 yard range on site. Have group therapy offering rifle and archery range time as blend of mindfulness/biofeedback.

But, somethings just stay as dreams.

 

[clozareal]

Massage chair during dental procedures seems...challenging. Seems like kind of a thing where you need the patient to stay still.

I mean it wasn't a vigorous massage chair.

 

[ObsequiousAplomb]

My vision of luxury would be this:

Log cabin as office building. Legit wood fireplace in waiting room and office. Add wood to fire mid appointment when necessary. Cigars permissible. Coffee/whiskey bar [*not for certain patients, and make clear, etc]. Deposit area for firearms in foyer. Animal heads everywhere. Animal hides/fur everywhere. Hefty quality wood furniture like Amish or better. Horse hitching post up front on rare chance someone were ever so inclined. Parking spots large enough for diesel trucks, with dual wheels. Include a payment scheme that includes goods/services. I.e. follow up visit could be paid with 30 mature laying hens, 12 months or younger. 6lbs moose meat. 7.5lbs black bear. 3/4 a cord of wood.

Have a 100 yard range on site. Have group therapy offering rifle and archery range time as blend of mindfulness/biofeedback.

But, somethings just stay as dreams.

Having grown up in the country, I like a lot of this. I can't imagine the liability of having a combination rifle range and outpatient psychiatry clinic though.

 

[dl2dp2]

Massage chair during dental procedures seems...challenging. Seems like kind of a thing where you need the patient to stay still.

My vision of luxury would be this:

Log cabin as office building. Legit wood fireplace in waiting room and office. Add wood to fire mid appointment when necessary. Cigars permissible. Coffee/whiskey bar [*not for certain patients, and make clear, etc]. Deposit area for firearms in foyer. Animal heads everywhere. Animal hides/fur everywhere. Hefty quality wood furniture like Amish or better. Horse hitching post up front on rare chance someone were ever so inclined. Parking spots large enough for diesel trucks, with dual wheels. Include a payment scheme that includes goods/services. I.e. follow up visit could be paid with 30 mature laying hens, 12 months or younger. 6lbs moose meat. 7.5lbs black bear. 3/4 a cord of wood.

Have a 100 yard range on site. Have group therapy offering rifle and archery range time as blend of mindfulness/biofeedback.

But, somethings just stay as dreams.

Not quite. Luxury experiential has nothing to do with massage chairs and wood fireplaces in waiting rooms. These are things you can find at a mall.

Plus, a lot of what I do is over Zoom now. So none of this is where the money is. It's more about what you say than what furniture is in your office. It might actually require a REDUCTION of things in your office. It's more about understanding what people who are willing to pay and what they really want. Historically, it's pretty clear that classical psychoanalysis is a luxury experiential product but we have more now.

 

[romanticscience]

Not quite. Luxury experiential has nothing to do with massage chairs and wood fireplaces in waiting rooms. These are things you can find at a mall.

Plus, a lot of what I do is over Zoom now. So none of this is where the money is. It's more about what you say than what furniture is in your office. It might actually require a REDUCTION of things in your office. It's more about understanding what people who are willing to pay and what they really want. Historically, it's pretty clear that classical psychoanalysis is a luxury experiential product but we have more now.

@dl2dp2 Reading your posts, I have sensed that you value evidence-based, scientifically valid care. However, it seems many of the affluent value "functional, wellness, holistic, and integrative" things. What are your thoughts on balancing both? How do you “sell” something like schema-focused therapy lol? By the way, do you do this? I’ve looked into the economics of offering it to those with personality disorders (which seems to be like everyone nowadays in PP) to be open and honest about what works best and how it would cost. Based on the studies, at my rates, it would cost them about~ $40k over the course of treatment.

As always, I appreciate your thoughts!

 

[dl2dp2]

@dl2dp2 Reading your posts, I have sensed that you value evidence-based, scientifically valid care. However, it seems many of the affluent value "functional, wellness, holistic, and integrative" things. What are your thoughts on balancing both? How do you “sell” something like schema-focused therapy lol? By the way, do you do this? I’ve looked into the economics of offering it to those with personality disorders (which seems to be like everyone nowadays in PP) to be open and honest about what works best and how it would cost. Based on the studies, at my rates, it would cost them about~ $40k over the course of treatment.

As always, I appreciate your thoughts!

No. I think it’s a misconception that the affluent wants snake oil. Snake oil is the opposite of luxury.

Peter Attia is probably the most “luxury” example in this space and his approach is exactly the opposite. He is “over-evidenced” and he never oversells things he thinks are helpful but is of less than great evidence. I think this is closer to what I want but it’s still not direct movable to mental health.

Science and technology as a marketing tool can have features of luxury product. The best example is Apple/Tesla. There are other competing pitches in psychiatry tho, like the analysis-existential-Irvin Yalom story (psychiatry not as treatment but as “enrichment”). That’s definitely a luxury product. And those are closer to the French style of luxury (LVMH), etc. so there’s a relative balance here. These are just some general ideas I’m toying around.

Without a question there’s a huge demand nationwide for 40k course of schema focused therapy, especially when combined with rational psychopharmacology. Problem is that the psychotherapy space and the combined treatment space is just not marketed in this way and it’s hard to find people. And yes because I cannot find a schema therapist easily and end up doing it myself.

Frankly it’s hard to find a therapist to be willing to do therapy on the sicker patients I have. Therapists don’t want to see sick people in general outside of say a day program. Of course the end result is I raise my fee even more.

 

[smalltownpsych]

No. I think it’s a misconception that the affluent wants snake oil. Snake oil is the opposite of luxury.

Peter Attia is probably the most “luxury” example in this space and his approach is exactly the opposite. He is “over-evidenced” and he never oversells things he thinks are helpful but is of less than great evidence. I think this is closer to what I want but it’s still not direct movable to mental health.

Science and technology as a marketing tool can have features of luxury product. The best example is Apple/Tesla. There are other competing pitches in psychiatry tho, like the analysis-existential-Irvin Yalom story (psychiatry not as treatment but as “enrichment”). That’s definitely a luxury product. And those are closer to the French style of luxury (LVMH), etc. so there’s a relative balance here. These are just some general ideas I’m toying around.

Without a question there’s a huge demand nationwide for 40k course of schema focused therapy, especially when combined with rational psychopharmacology. Problem is that the psychotherapy space and the combined treatment space is just not marketed in this way and it’s hard to find people. And yes because I cannot find a schema therapist easily and end up doing it myself.

Frankly it’s hard to find a therapist to be willing to do therapy on the sicker patients I have. Therapists don’t want to see sick people in general outside of say a day program. Of course the end result is I raise my fee even more.

Working with the sicker patients and charging for it is what I do and a lot of what you say resonates with my own experience. Part of why most outpatient therapists don’t want to work with the sicker patients is because the insurance based system isn’t conducive to the type of treatment support that these patients need. I see it from the other perspective where psychiatrists aren’t willing to see my patients. Mist psychiatrists and PMHNPs that I meet seem to think they should have a huge panel with monthly appointments until that can be stretched into longer intervals. I don’t think this is an artifact of thinking about treatment as much as that is what systems create and people think that is how it should be.
I know that my patients would rather pay multiples of the going rate for psychiatry for better care, but you can’t charge more to these patients than you can to insurance patients and provide better treatment. You’re either all in or you’re all out of the system.

 

[Candidate2017]

If I were to ever go private practice it would be for the related reasons of being super tired of the "I'm pretty sure I have ADHD and ASD and need you to give me Adderall" intakes and the lack of true control over panel size/return rate. But opting out of 25-50% of consumer demand could limit your ability to fill a practice quickly.

I don't know what's worse. That a good chunk of psychiatry can be considered consumer demand for inappropriate diagnoses that get them a grab bag of goodies and other benefits, or that PP psychiatry panels won't fill quickly if practice appropriately.

From what I see, PP involves a lot of controlled sub seekers and doling out such. And the higher the socioeconomic status, "consumers" are more likely to get what they want. College kids, execs, rich housewives. In PP, the people with money have an actual consumer mindset, as opposed to random Medicaid patients at a Big Box shop (the real consumer in those places is the govt and the Big Box).

My vision of luxury would be this:
Log cabin as office building. Legit wood fireplace in waiting room and office. Add wood to fire mid appointment when necessary. Cigars permissible.

But you're still seeing patients. That ruins the luxury experience.

 

[clozareal]

From what I see, PP involves a lot of controlled sub seekers and doling out such. And the higher the socioeconomic status, "consumers" are more likely to get what they want. College kids, execs, rich housewives. In PP, the people with money have an actual consumer mindset, as opposed to random Medicaid patients at a Big Box shop (the real consumer in those places is the govt and the Big Box).

I do see many entitled patients in my PP and I get consultation on how to set boundaries. I’d much rather deal with “give me Adderall because I lack focus and productivity” since I’m pretty good at trying to assess for the reason why they want Adderall and can suggest behavioral interventions or med recs for comorbidties if they don’t meet criteria. I try to whiff out personality disorders and those who won’t be collaborative in the phone screen, which I always do before I take them on as patients. It’s uncompensated monetarily but really prevents me from more headaches down the road. I probably get one intake every few months that’s entitled beyond reason and usually I discharge them from my PP or they don’t stick around since they don’t like being told no so often.

Medicaid patients I had were entitled on a different level. It was a lack of understanding what I could and couldn’t do and there was little negotiation or collaboration on what it takes to improve their station. Many of them were more personality disordered and demanding of controlled substances than my wealthy patients. With that being said, most of my Medicaid patients were pleasant and really trying their best to work with what they have. It was really lovely except for that 10-20% of intakes that were completely unreasonable.

 

[Merovinge]

I do see many entitled patients in my PP and I get consultation on how to set boundaries. I’d much rather deal with “give me Adderall because I lack focus and productivity” since I’m pretty good at trying to assess for the reason why they want Adderall and can suggest behavioral interventions or med recs for comorbidties if they don’t meet criteria. I try to whiff out personality disorders and those who won’t be collaborative in the phone screen, which I always do before I take them on as patients. It’s uncompensated monetarily but really prevents me from more headaches down the road. I probably get one intake every few months that’s entitled beyond reason and usually I discharge them from my PP or they don’t stick around since they don’t like being told no so often.

Medicaid patients I had were entitled on a different level. It was a lack of understanding what I could and couldn’t do and there was little negotiation or collaboration on what it takes to improve their station. Many of them were more personality disordered and demanding of controlled substances than my wealthy patients. With that being said, most of my Medicaid patients were pleasant and really trying their best to work with what they have. It was really lovely except for that 10-20% of intakes that were completely unreasonable.

I really doubt anyone who has spent years working with medicaid and years working with the top 1% SES would have the conclusion that the top 1% are less reasonable or more substance seeking. I do love working with the Medicaid population but ho boy there were some serious zingers sprinkled in there in a way you just do not find with the wealthy. Had a dad repeatedly calling his 8 yo son the N word (they were both Caucasian), I thought I misheard him the first time and when I heard it a second time and redirected him, he screamed so loud they could hear it in a neighboring surgical center that was through two huge concrete walls. Got about 50 different slurs hurled my way as security escorted him from the premises...

 

[Candidate2017]

I do see many entitled patients in my PP and I get consultation on how to set boundaries. I’d much rather deal with “give me Adderall because I lack focus and productivity” since I’m pretty good at trying to assess for the reason why they want Adderall and can suggest behavioral interventions or med recs for comorbidties if they don’t meet criteria. I try to whiff out personality disorders and those who won’t be collaborative in the phone screen, which I always do before I take them on as patients.

PP is actually too broad a term. Self/owner-PP, which you seem to be, is very different from large group PP, which may not allow much screening. Self-PP allows autonomy, which allows screening, which cuts down on entitled patients.

Medicaid patients I had were entitled on a different level.

In America, the poor get govt entitlements. No one tells them what to do. The are the boss of themselves. They can party 7 days a week, blow their cash on drugs and drink, rinse and repeat. We are their servants (via the taxes we pay and/or directly providing them psychiatric services). So, the rich and poor in America are more alike than different. Both ends of the spectrum are entitled.

One thing to note is the rich can afford to fund lawsuits and pay lawyers to zealously pursue trivial nonsense if they feel offended in some way. There's a reason malpractice insurance applications ask if you regularly treat celebrities and pro athletes. Let's not forget those who like to mention they are friends with the hospital CEO and board members, etc.

At the end of the day, we pick our poison, we pick our patient population.

I really doubt anyone who has spent years working with medicaid and years working with the top 1% SES would have the conclusion that the top 1% are less reasonable or more substance seeking. I do love working with the Medicaid population but ho boy there were some serious zingers sprinkled in there in a way you just do not find with the wealthy. Had a dad repeatedly calling his 8 yo son the N word (they were both Caucasian), I thought I misheard him the first time and when I heard it a second time and redirected him, he screamed so loud they could hear it in a neighboring surgical center that was through two huge concrete walls. Got about 50 different slurs hurled my way as security escorted him from the premises...

You've posted this story before. I find it interesting this is the best example you have of egregiousness entitlement (or that you are shocked by non-blacks addressing non-blacks by the N word). In reality, this is just another day before lunch for the average psychiatrist who doesn't work at a boutique PP for the worried well.

 

[Merovinge]

PP is actually too broad a term. Self/owner-PP, which you seem to be, is very different from large group PP, which may not allow much screening. Self-PP allows autonomy, which allows screening, which cuts down on entitled patients.




In America, the poor get govt entitlements. No one tells them what to do. The are the boss of themselves. They can party 7 days a week, blow their cash on drugs and drink, rinse and repeat. We are their servants (via the taxes we pay and/or directly providing them psychiatric services). So, the rich and poor in America are more alike than different. Both ends of the spectrum are entitled.

One thing to note is the rich can afford to fund lawsuits and pay lawyers to zealously pursue trivial nonsense if they feel offended in some way. There's a reason malpractice insurance applications ask if you regularly treat celebrities and pro athletes. Let's not forget those who like to mention they are friends with the hospital CEO and board members, etc.

At the end of the day, we pick our poison, we pick our patient population.




You've posted this story before. I find it interesting this is the best example you have of egregiousness entitlement (or that you are shocked by non-blacks addressing non-blacks by the N word). In reality, this is just another day before lunch for the average psychiatrist who doesn't work at a boutique PP for the worried well.

I have a lot more but that one stands out for the sheer intensity and absurdity of the situation. To come into a child clinic and expect to rain severe obscenities at your own child and then at the physician for calling you out on those obscenities to the point of bringing in staff/security from several neighboring wings of the office is not an average day before lunch for employed psychiatrists. I trained in fellowship with very low SES patients making up the bulk of our patients and had only a few situations even close to that through 2 years.

 

[clozareal]

PP is actually too broad a term. Self/owner-PP, which you seem to be, is very different from large group PP, which may not allow much screening. Self-PP allows autonomy, which allows screening, which cuts down on entitled patients.

That's true. I'm solo PP and don't have to deal with random patients being put on my schedule that I have no control over. I screen very carefully to select out personality disorders. I also don't take any insurance which probably helps. The autonomy is unparalleled.

 

[dl2dp2]

From what I see, PP involves a lot of controlled sub seekers and doling out such. And the higher the socioeconomic status, "consumers" are more likely to get what they want. College kids, execs, rich housewives. In PP, the people with money have an actual consumer mindset…

Not if you do good combined treatment with substantial insight oriented focus (i.e. core belief restructuring, schema reformatting, confrontation of subconscious, whatever theoretical orientation you have).

When you do that your treatment tends to elevate things a lot more than providing a consumer what they want in terms of meds. Meds are an instrument. Insight provide treatment goals that actually move the needle. A lot of times wealthy people don’t want to take meds they actually need. Others prefer to be boxed into a diagnosis and resist change. This is what you call consumer mindset. But that’s precisely the focus of clinical attention if you do a good job with combined treatment.

I have the time and luxury to handle the very complex countertransference with patients and families of deprescribing the 10 meds my borderlines are on… this is very very hard to get with a facilities job. And the irony is that these patients end up sticking with me longer as opposed to their previous MD who writes whatever med they wanted. This is not magic. It’s just Glen Gabbard GPM. Evidence based. Science. lol. But in real life this becomes akin to luxury. It’s really funny how it works.