Private Practice Musings

[randomdoc1]

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I have to admit, although this is what worked for me, I took a very different approach in some aspects. I spent extravagantly up front. But, I guess it boils all down to profit and loss right? If you expend little, it's hard to lose too much. Spend more, risk is higher. But if spent well, potential gains are higher. It worked for me though : ). Thanks splik! When I find time, I plan to write up my journey too! It was very different from you and @Sushirolls . It almost feels like a bit of a mafia like culture. People get nasty and change when it comes to money lol, and there's a lot of people you are working with if the practice grows.

 

[ksharp33]

I have to admit, although this is what worked for me, I took a very different approach in some aspects. I spent extravagantly up front. But, I guess it boils all down to profit and loss right? If you expend little, it's hard to lose too much. Spend more, risk is higher. But if spent well, potential gains are higher. It worked for me though : ). Thanks splik! When I find time, I plan to write up my journey too! It was very different from you and @Sushirolls . It almost feels like a bit of a mafia like culture. People get nasty and change when it comes to money lol, and there's a lot of people you are working with if the practice grows.

would love to hear your story!

 

[tr]

I have taken this approach and have sought out extensive reproductive psych experience during residency. In a niche such as this (or the others you listed), do you think very high rates right out of residency are to be avoided? When I start practice later this summer, do I go for the high hourly rates right away? I know that I do good work and bring something to the table a lot of psychiatrists in the area lack (and thus refer to our repro psych clinic for), but I'm worried how fast I'll be able to attract patients with four-figure intakes.

I'm guessing for this type of practice networking with local OBGYN would be the best route to fill?

Yes network with Ob. Go in person and hand them a bunch of cards. Most community Ob practices don't have good referrals for repro psych and will probably be thrilled to send you people.

If you aren't under immediate financial pressure I wouldn't start by undercharging. It is going to be hard to raise rates later on established patients, and you will end up with a patchwork of people paying different rates that will be hard to keep track of.

I would aim for market rates and just position yourself as someone with special expertise who is worth the money.

 

[jbomba]

Yes network with Ob. Go in person and hand them a bunch of cards. Most community Ob practices don't have good referrals for repro psych and will probably be thrilled to send you people.

If you aren't under immediate financial pressure I wouldn't start by undercharging. It is going to be hard to raise rates later on established patients, and you will end up with a patchwork of people paying different rates that will be hard to keep track of.

I would aim for market rates and just position yourself as someone with special expertise who is worth the money.

Thanks for your thoughts.

I will be doing inpatient work when I start and building the practice over time. I'm hoping to be full within 9-12 months (full being ~15 hours a week). The inpatient side should more than take care of things while I'm filling so I'm not too concerned about getting people in the door right away.

I think my biggest question is how do I locate OB practices despite my being in a big coastal city. Most seem associated with hospital systems who presumably have their own psychiatrists. Do I just go into the office regardless and leave cards for the receptionist to pass to the docs?

 

[ObsequiousAplomb]

Thanks for your thoughts.

I will be doing inpatient work when I start and building the practice over time. I'm hoping to be full within 9-12 months (full being ~15 hours a week). The inpatient side should more than take care of things while I'm filling so I'm not too concerned about getting people in the door right away.

I think my biggest question is how do I locate OB practices despite my being in a big coastal city. Most seem associated with hospital systems who presumably have their own psychiatrists. Do I just go into the office regardless and leave cards for the receptionist to pass to the docs?

Googling can help you find OBs that aren't in the hospital system.
Driving by office space with physicians and seeing the ones that are advertised as OBGYN would also help.
If you ask one of the OBs who is in the hospital system if they know any private practice OBs in the area they will probably know many of them.
Same thing with family medicine.

 

[jbomba]

Googling can help you find OBs that aren't in the hospital system.
Driving by office space with physicians and seeing the ones that are advertised as OBGYN would also help.
If you ask one of the OBs who is in the hospital system if they know any private practice OBs in the area they will probably know many of them.
Same thing with family medicine.

Was also thinking pediatrics might be a good route. They're doing a lot of well child visits for newborns, presumably encountering mothers who are experiencing postpartum psychiatric symptoms.

 

[tr]

Thanks for your thoughts.

I will be doing inpatient work when I start and building the practice over time. I'm hoping to be full within 9-12 months (full being ~15 hours a week). The inpatient side should more than take care of things while I'm filling so I'm not too concerned about getting people in the door right away.

I think my biggest question is how do I locate OB practices despite my being in a big coastal city. Most seem associated with hospital systems who presumably have their own psychiatrists. Do I just go into the office regardless and leave cards for the receptionist to pass to the docs?

Whom do the patients in your academic repro psych clinic see for obstetric care? Are they all internal to your medical center? I'm in a big hospital system but I see a lot of psych patients who get their Ob care elsewhere, either in the community or at one of the other AMCs.

 

[clozareal]

Thanks for your thoughts.

I will be doing inpatient work when I start and building the practice over time. I'm hoping to be full within 9-12 months (full being ~15 hours a week). The inpatient side should more than take care of things while I'm filling so I'm not too concerned about getting people in the door right away.

I think my biggest question is how do I locate OB practices despite my being in a big coastal city. Most seem associated with hospital systems who presumably have their own psychiatrists. Do I just go into the office regardless and leave cards for the receptionist to pass to the docs?

I wouldn’t assume that hospital systems have their own psychiatrists. Even if they do, they might be full or have an unreasonably long waitlist. Most patients with PPD/PPA want to be seen right away so a one month waitlist is even too long.

Find birth centers because most postpartum units make new moms fill out an EDS. Try to get on their list of discharge referrals. Their OBs might want good referrals too so I would reach out to them and offer to meet with them or buy their office staff lunch and leave your business cards. It’s better to have more referrals than less.

Find postpartum support groups or therapists that run them to talk to.

 

[Stagg737]

Was also thinking pediatrics might be a good route. They're doing a lot of well child visits for newborns, presumably encountering mothers who are experiencing postpartum psychiatric symptoms.

Peds clinics, especially larger ones, would also be good. Not just the newborns either, a lot of parents with young kids are likely to have another child at some point and being on those pediatricians' radar could also land a few additional referrals.

 

[tr]

Was also thinking pediatrics might be a good route. They're doing a lot of well child visits for newborns, presumably encountering mothers who are experiencing postpartum psychiatric symptoms.

Peds is supposed to screen the moms for PPD but in practice it's really spotty. The mom is not their patient and I think a lot of the time they just don't want to know/don't consider it their issue to deal with. A few practices are more enlightened in this area but it may be difficult to figure out which those are. Ob may be higher yield.

 

[Celexa]

Thanks for your thoughts.

I will be doing inpatient work when I start and building the practice over time. I'm hoping to be full within 9-12 months (full being ~15 hours a week). The inpatient side should more than take care of things while I'm filling so I'm not too concerned about getting people in the door right away.

I think my biggest question is how do I locate OB practices despite my being in a big coastal city. Most seem associated with hospital systems who presumably have their own psychiatrists. Do I just go into the office regardless and leave cards for the receptionist to pass to the docs?

There isn't a system in this entire country that has enough mental health providers for all the referrals from their other practices. Even if they have in house mental health people will be thrilled to have another option for referrals.

 

[heartsink]

But depending on region, that can be very difficult for solo practitioners who have little negotiating power (and I know how to negotiate).

Somewhat of an aside, but where do you attribute your learning to negotiate? Any book recommendations?

 

[Psych Person]

I recently drank the private practice Kool aid and while I'm no expert being new to the game, wanted to share my thoughts and advice on starting a practice (these are just my opinions and I'm sure others will disagree):

1. I recommend keeping costs low. Very low. I think Sushi shot himself in the foot by spending extravagantly too early. Even if your goal is providing TMS etc (which I'm exploring for the future), start simple.
2. See if you can sublet an office to begin with, or even just start with telehealth and go from there (though I do anticipate many people will be wanting in person services and it is ideal to offer both). Don't start out with some expensive office especially if you are in a high CoL area.
3. If you have any thought of doing PP at some point in the future, get disability insurance now. One of my main expenses is disability insurance now. If I had gotten it when I was younger and a resident it would have been 1/3-1/2 what I'm paying now. I've calculated even if only became disabled in the last 4 yrs of my career, it would pay for itself vs putting that money in VTSAX etc even if you had to sue them to cover you. Which is to say it is absolutely worth it to get own occupation disability insurance for most psychiatrists. You can always cancel later if you think you have enough money and willing to take the risk.
4. Health insurance is v expensive if you can't get on your partner's plan.
5. Don't spend lots of money on a website. I've paid about $10/month and made it myself with a website builder and it looks pretty good. I've rarely seen someone with a professional made website that looked like it was worth it (usually they look worse than mine lol)
6. If your goal is a cash practice DO NOT start off accepting insurance under any circumstances. It much more efficient, economical, and sanity preserving not to deal with insurance if you are starting a solo practice. It is also MUCH EASIER to go from cash practice to insurance than the other way around. If you have a cash practice, insurance companies may offer you to join their network at much better rates than they would pay if you tried to join on your own. Also even if you have a cash practice you can still grow to do TMS by either spinning off neuromodulation into an insurance based practice OR doing single case agreements for TMS. I have also had good success at getting insurance companies to reimburse my pts for my full cash amount (it's called a network gap exception or "non-participating provider" authorization). Also difficult for insurance pts to transition to cash only. It will be a nightmare to get off panels once you are on them. You will be dead before they remove you!!! They call them ghost networks for a reason - most of the psychiatrists are literally ghosts.
7. DO accept credit cards etc. Round where I am I have been surprised how many pts have HSA cards in particular. These patients have high deductibles so they often have to pay $5000k+ before their insurance would cover in network care! Make sure to set your fees to account for CC fees.
8. Take advantage of offers from credit card processing companies. I got $20k free in processing fees with Stripe. Stripe doesn't negotiate but others will if you can show them a lower offer.
9. Encourage patients to pay by ACH payments especially if you have a therapy practice. It avoids credit card fees.
10. Get payment in advance of the appointment. I am very disorganized and would never get paid otherwise. If pts don't pay at least 48hrs before, appointment is canceled.
11. Consider offering discounts to patients with regular sessions who pay in advance. I offer 10% discount for twice weekly or more pts who pay for the whole month ahead of time (only ACH or wire transfers).
12. Don't set up a SEP-IRA. Set up a solo 401k so you can contribute to your back door Roth. Consider setting up a defined benefit plan.
13. Find a good accountant. This is one area where it's okay to spend money but don't get fleeced.
14. You probably don't need an attorney. A good accountant can help and your malpractice carrier will help with much of the rest.
15. Don't skimp on malpractice insurance either. That said, I recommend only getting the part time plan to begin with, and then upgrading once you actually work more that 20hrs pp.
16. Inform patients ahead of time that if they dispute credit card charges you will defend yourself with the minimum necessary information disclosed to the credit card company.
17. I recommend stating on your website etc that you don't prescribe controlled drugs. You can still prescribe controlled drugs but this *might* help avoid a flurry of drug seekers. Though somehow almost all pts coming to me on controlled drugs often multiple lol
18. Don't just accept any patients because you are scared of not filling. Be selective. Will save a lot of headaches in the long run. Not worth it to take on unsuitable or red flag patients.
19. Consider including a personality disorder screener such as the IPDE screener or SCID-5-SPQ in your intake paperwork. I like working with many types of PD but it helps to head off issues and screen out certain pts early.
20. Offer to do some talks on psych topics for other physicians.
21. Remember to let your psychiatry colleagues know you are accepting pts.
23. PCPs and specialist physicians are likely a better source of referral than therapists.
24. Email is a good way of contacting people to let them know you are available. I felt really weird and awkward about this but was surprised to find some people were excited to receive my info. I already had the info for the physicians I wanted to contact, and found the info for psychologists on the ABPP and state psychological association directory.
25. I wouldn't spend money on things like advertising on SEO management to begin with. That can come later if needed. The lower you can keep your costs, the more breathing room you have for your practice to grow.
26. Avoid using Alma, Headway, SonderMind, Grow Therapy or any of these other companies if you can avoid them. They will be the death knell of the profession.
27. Try to diversify your offerings beyond seeing patients for ongoing care. I also offer second opinion chart reviews nationally and internationally, provide one time consults, extended evals for complex cases (6-8hrs), consultation to therapists and other physicians, supervision, talks/lectures, consulting regarding documentation and coding/billing, and do forensic work. This diversity keeps me feeling invigorated and provides good revenue streams beyond direct patient care.
28. Consider providing some pro bono or low fee/sliding scale appointments in your practice. Still figuring out the best way to do this as was very annoyed when one pt who I said I would see for a pro bono consult canceled less than 24hrs before. May start asking for a small deposit.
29. Take the down time to work on admin tasks, building your website, building your brand, networking, reading, and doing courses. Am doing several therapy trainings which has been great.

Have not lost any money in the months I have left my job. It does help that I already had an established reputation, inbuilt referral source from my last job, some patients following me into pp, diversified revenue streams and most of all kept my expenses low.

BTW, I was most always set on academic type practice, private practice was never on the horizon for me but it's going well thus far (brought in an average of 10k/month after expenses for first 3 months and have mostly not been working). I'm still in the honeymoon phase but I feel like I have my dream job (mostly). My physical and mental health are much better as is my work-life balance. Am worried about how impending recession and wide scale layoffs will impact fledgling practice. That said, I think you have to have some business savvy though many people seem to get by with little sense of it. I also took some free online courses in accounting and marketing in my down time. If you just want to focus on seeing pts and switching off at the end of the day, having your own private practice may not be for you.

I’ve learned so much from you over the years (lurking and on my own SDN account for 7+ years). You’ve also conducted yourself in an often kind, warm, humorous and relatable manner. For people like me who grew up with no frank advantages (other than the mind and body I was born with), few resources (professional, relational, and financial) and had no real-life individuals in medicine or psychiatry to learn from, people like you make an enormous difference in our lives. I wouldn’t have been able to make good strategic and informed decisions to the degree that I have without you and a number of others. Appreciate you very much. Consider this my long-overdue “thank you, thank you, THANK YOU!” Much love and God bless you.

 

[Merovinge]

I’ve learned so much from you over the years (lurking and on my own SDN account for 7+ years). You’ve also conducted yourself in an often kind, warm, humorous and relatable manner. For people like me who grew up with no frank advantages (other than the mind and body I was born with), few resources (professional, relational, and financial) and had no real-life individuals in medicine or psychiatry to learn from, people like you make an enormous difference in our lives. I wouldn’t have been able to make good strategic and informed decisions to the degree that I have without you and a number of others. Appreciate you very much. Consider this my long-overdue “thank you, thank you, THANK YOU!” Much love and God bless you.

100% agree about Spilk and separately about how important mentorship is in medicine. It makes such a big difference to have the feeling of someone you respect "take you under their wing". Med school felt very hard and confusing at times not knowing anyone in the field or having any mentorship. I was so fortunate to have great mentorship in residency and fellowship and cannot imagine what it's like for people who go to programs and don't have that opportunity.

 

[jbomba]

There isn't a system in this entire country that has enough mental health providers for all the referrals from their other practices. Even if they have in house mental health people will be thrilled to have another option for referrals.

Fair point. You think the best option to target these practices nonetheless is to just go in, introduce myself to the receptionist and leave cards? I imagine getting docs to get back to me by phone/email will be tough.

 

[troutscout]

You can also focus on marketing to your niche - the patient demographic you are intending to work with - whether that be through good, well-worded website copy that speaks to your ideal patient or other options such as consistent social media posting and blog posts that increase your SEO.

 

[clozareal]

Fair point. You think the best option to target these practices nonetheless is to just go in, introduce myself to the receptionist and leave cards? I imagine getting docs to get back to me by phone/email will be tough.

Yeah going in to meet them or emailing/calling are the options. You can also offer to buy the clinic staff lunch for the day and leave your business cards, which is another memorable way to get their business.

 

[splik]

Update
It's been 4 months since I officially launched my PP.

I've experienced the following challenges:
1. Low rate of converting inquiries into patients
2. Patients dropping off or being lost to contact (this is probably a good thing I think)
3. Lots of personality disorder patients. I like working with some degree of PD but it's a lot of responsibility to parent someone possibly for the rest of your career, and there's only so many of these patients you can treat.
4. Managing my own difficulty (?guilt) with patients who can't afford my rates. I had some bad experiences with offering pro bono consults and I'm not flush with cash right now, so no longer offering this.
5. unraveling a bit with lack of structure to my day.
6. Physicians referring pts to me without telling them I'm private pay.
7. Insurance companies playing dirty tricks to minimize OON payments to my patients.
8. tried a virtual assistant but it didn't work out

On the positive side:
1. So far made a little over 12k per month after expenses. Not great but not losing money. (This includes forensic, consulting, and chart review). Am owed some for forensic and chart review, so expecting a good amount additional to come in over the next few months.
2. Have some great patients who I enjoy working with.
3. Getting referrals from people I've never heard of, so word is getting out.
4. working very little compared to before.
5. Enjoying doing more forensic work than I did before and with greater variety.
6. Very happy with the quality of care I'm able to provide.
7. Have had time to do some specialized therapy trainings which I wouldn't have been able to do in my old job. Looking forward to do additional trainings this year too.
8. have some vacations coming up and don't need anyone's blessing to do so.

My insistence of keeping a highly specialized practice means it is taking me longer to fill. I hate general adult outpatient psychiatry. In addition, I really can't cope with seeing patients infrequently so I'm not really accepting patients for meds only unless they're too demented for therapy. I would have more patients if it weren't for that, but I feel happy with that. I also feel confident I can make this work even though I am definitely out of my comfort zone. I've been told it takes about a year to fill a practice with 20-24 hrs (which is considered "full time") in my area. However, even if I can have consistently 10hrs per week by that time, with all my other work it will come out okay for me.

Hoping to diversify my work further too.

I'm considering taking some part time work but not sure it's worth it.

 

[Sushirolls]

Negatives:
1-7 Yep, and yep, lots of yeps.
8, thankfully I didn't have to go there.

Positives:
1-That's amazing!!!
2, 3 - Yep and yep
4 - I've sort of experienced this?
5- not doing forensics, kudos for you!
6 - Amen! Agree
7 - Yes the freedom to do any CME when you please as you please.
8 - One of the best things ever! Agree.

If you don't HAVE to take part time work, don't, not worth it.

Applause to you @splik

 

[clausewitz2]

Great Moments in Private Practice History, #4,792:

A colleague wants to refer a patient to me that is a relative of a family friend who has an issue directly related to my niche. Turns out I don't take their insurance and they're not willing to cash-pay yet; colleague asks me if I know any other psychiatrists in the area specializing in [NICHE]

It takes me a minute, but I can honestly respond "No, no I don't. I'm really the only one in town outside of ACADEMIC CENTER." I realize I am now officially the [NICHE] Guy.

Later that week, a patient I have never met presents for intake despite being concurrently in an IOP, having already convinced their IOP that their problems with [SUBSET OF NICHE] are severe enough that they need to be seeing me, the [NICHE] Guy. IOP confirms they are fine with this and feels the [NICHE] issues patient has are outside of what they are equipped to deal with.

Feels good, man.

 

[Sushirolls]

Bless your heart for being a niche person. And applause to you, too @clausewitz2

Anecdote, I had a physician patient in past who was grumbling about paying my cash rate because I wasn't in network with their UHC. Doc eventually dropped me. Always interesting to see the people who value or don't services in context of their clear means to afford.

I've dropped that mindset goal of any niche.
Call me the generalist. I'm easing into this role and okay with just being a general adult psychiatrist. Just want to pay my bills, and have time for family, farming and hunting.

Turkey season is approaching folks, time to change your choke tubes!

 

[clozareal]

If you're already struggling with unraveling because of your unstructured day, taking part time work is going to take away from the psychological space to think about your private practice and make you lose focus.

 

[splik]

Update
It's the end of my 6th month since since I officially launched my PP.

It's been going really well, feeling really happy about how things have been going. After some very slow months I've been getting quite a steady stream of referrals. Most come from the two big academic centers round here, otherwise from other psychiatrists and some psychologists/therapists. I've been feeling less isolated and have more structure. Currently it's averaged out at a little under 16k/month after expenses (and this month was over 45k after expenses). However, this includes forensic work and consultation in addition to clinical work which bumps it up quite a bit. I do 2nd opinion chart reviews, and also provide consultation to pp docs and large organizations re: billing and clinical documentation integrity etc. My goal would be about 32k/month on average after expenses which I think is doable by the end of the yr. It would likely be with some variability though as some months are busier than others.

My patient population is less diverse than I am used to and I get more narcissistic patients than I'm used to. However, things seem to be going great right now even with some patients with severe personality disorders. That I attribute to being able to see such pts multiple times per week, the costs screening in only motivated patients, and having relatively firm boundaries.

I deleted my psychology today profile after 3 months. I didn't get a single patient inquiry turn into an actual patient. I attribute this to my niche practice. But most pts referred to me know that I am cash based and have received a recommendation often from someone they trust, and that goes much farther than a psychology today ad.

Also interestingly, I was about to lose hope with having a narrow niche and started advertising to accept a broader range of patients. However, almost immediately, my practice started filling with patients with my niche population and I no longer wanted to accept patients outside of that!

I had planned on 20 clinical hours a week but I'd actually be fine with 15 as that feels quite draining to me now (especially as I see several pts for intensive psychotherapy).

Now I'm about to go on my first 2 week vacation out of the country since starting PP. I have taken 2 weeks off for vacation since starting PP (not including christmas which I block off) and a week for a conference. I've also done a few therapy trainings which it is great to have the time for. I don't have coverage, but none of my pts should need refills so hopefully no disasters while I'm away.

p.s. I am also increasingly convinced that insurance companies are a singular evil in the medical-industrial complex.

 

[jbomba]

Thanks splik. Curious how many clinical (non forensic) hours you are doing and what the income is from those hours specifically.

 

[splik]

Thanks splik. Curious how many clinical (non forensic) hours you are doing and what the income is from those hours specifically.

I won't get into my rates, which vary between activities and patients but can tell you this past week I did 15 clinical hours and brought in a little over 7500 before expenses.

 

[jbomba]

The best place to find location-specific out of network reimbursement/fee is from Welcome to FAIR Health

The best place to find insurance-driven reimbursement rate is Medicare's website. If you base your calculation on that number you might be pleasantly surprised.

EMR is a small piece of the puzzle. They typically cost around $100 a month. Any number of vendors with EPCS would work well.

I checked out that website. Not sure how I make use of the data. For example, in my location out of network 99214 + 90833 is $385 + $300.

How does this help me?

 

[rjs2131]

I feel like this type of work is right up my alley…any advice on how to get started?

consultation to pp docs and large organizations re: billing and clinical documentation integrity etc

 

[splik]

I feel like this type of work is right up my alley…any advice on how to get started?

typically becoming a consultant means getting the requisite experience for people to request your services. This would be for example as a medical director of coding of CDI, working for an IPRO doing peer reviews, working for an insurance company as a medical director and getting familiar with managed care and utilization management etc. You could also get certification in coding, auditing, and/or compliance. There are also jobs working for mckesson and mcg etc though they don't tend to pay well. Many of these jobs are quite competitive.

 

[forchinet121]

typically becoming a consultant means getting the requisite experience for people to request your services. This would be for example as a medical director of coding of CDI, working for an IPRO doing peer reviews, working for an insurance company as a medical director and getting familiar with managed care and utilization management etc. You could also get certification in coding, auditing, and/or compliance. There are also jobs working for mckesson and mcg etc though they don't tend to pay well. Many of these jobs are quite competitive.

Why competitive if they don’t pay well?

 

[splik]

It's coming to the end of my first year of private practice! I had low expectations. I was so burnt out from my last job I really didn't have it in me to put in a lot of effort to starting and growing a practice. I was hoping to make over $200k my first year after expenses, and I've brought in a little under $310k after expenses. I've probably averaged under 15 hours per week over the course of the past 12 months. I was working well over 40hrs a week in average in academics (?maybe 60), much of it uncompensated. So 1/4 of the work for 3/4 of the pay I would say is pretty good.

The above figures include forensic work, consulting, and chart reviews. If it was just clinical work seeing patients it would be a lot lower. That said, I have not put much effort into marketing, networking etc at this point in time. I have a relatively small number of physicians and psychologists who have referred the bulk of patients I've seen. I'm on the referral lists for the 3 major academic centers in the vicinity.

It can be stressful sometimes dealing with some challenging patients. That is true in any setting but it's easier to feel unsupported and that your own reputation and brand is on the line as a solo practitioners. It's also been really wonderful to see patients who were really unwell now doing really well and provide them with the high level of care I wish more pts had access to.

I do miss some of the zebras I had in academics. However I still do some case consultation to the residents and attendings for weird cases and also get to do some interesting chart reviews and forensic cases!

When I started pp I think I felt a little uncomfortable about how much I charged and about my worth. Now having dealt with some of the BS that comes with both clinical and forensic work, I feel I am worth every penny. We have to contain a lot of powerful emotions, expose ourselves repeatedly to traumatic materials, manage the transference enactments of patients and their relatives, and manage risk. All of that puts a premium on this kind of work. I'm also able to provide expert opinion chart reviews to minimum wage workers through one of my contracts, and treatment to a highly marginalized pt population through my pp with another. All of which is highly compensated.

My plans for the next year are to grow my clinical practice, and branch out into some other non clinical areas I've really wanted to pursue but haven't made the time for. I have 3 things I would like to do (all psych-adjacent). I never in a million years thought I would end up doing private practice. Now I think it is where I belong and what I was meant to do.

 

[finalpsychyear]

It's coming to the end of my first year of private practice! I had low expectations. I was so burnt out from my last job I really didn't have it in me to put in a lot of effort to starting and growing a practice. I was hoping to make over $200k my first year after expenses, and I've brought in a little under $310k after expenses. I've probably averaged under 15 hours per week over the course of the past 12 months. I was working well over 40hrs a week in average in academics (?maybe 60), much of it uncompensated. So 1/4 of the work for 3/4 of the pay I would say is pretty good.

The above figures include forensic work, consulting, and chart reviews. If it was just clinical work seeing patients it would be a lot lower. That said, I have not put much effort into marketing, networking etc at this point in time. I have a relatively small number of physicians and psychologists who have referred the bulk of patients I've seen. I'm on the referral lists for the 3 major academic centers in the vicinity.

It can be stressful sometimes dealing with some challenging patients. That is true in any setting but it's easier to feel unsupported and that your own reputation and brand is on the line as a solo practitioners. It's also been really wonderful to see patients who were really unwell now doing really well and provide them with the high level of care I wish more pts had access to.

I do miss some of the zebras I had in academics. However I still do some case consultation to the residents and attendings for weird cases and also get to do some interesting chart reviews and forensic cases!

When I started pp I think I felt a little uncomfortable about how much I charged and about my worth. Now having dealt with some of the BS that comes with both clinical and forensic work, I feel I am worth every penny. We have to contain a lot of powerful emotions, expose ourselves repeatedly to traumatic materials, manage the transference enactments of patients and their relatives, and manage risk. All of that puts a premium on this kind of work. I'm also able to provide expert opinion chart reviews to minimum wage workers through one of my contracts, and treatment to a highly marginalized pt population through my pp with another. All of which is highly compensated.

My plans for the next year are to grow my clinical practice, and branch out into some other non clinical areas I've really wanted to pursue but haven't made the time for. I have 3 things I would like to do (all psych-adjacent). I never in a million years thought I would end up doing private practice. Now I think it is where I belong and what I was meant to do.

Fantastic. Do you plan to increase hours at all to equal your previous salary or plan to stick to 15/hrs only? Seems like if you go from 1/4 to 1/3 previous job hours worked you would easily hit your targets.

 

[romanticscience]

Are you still considering offering TMS?

 

[splik]

Fantastic. Do you plan to increase hours at all to equal your previous salary or plan to stick to 15/hrs only? Seems like if you go from 1/4 to 1/3 previous job hours worked you would easily hit your targets.

I've already increased my hours. The under 15hrs is averaged out over the whole year and things picked up a lot in the latter part of the year (so I've done over 20hrs many weeks in recent months). Though my clinical practice has slowed down a bit recently. I hope to surpass my previous employed salary, if not next yr, then the yr after. I'm very selective about pts I take on and also forensic cases. Have turned down some high profile cases because I just had a bad feeling about them.

Are you still considering offering TMS?

Not for the forseeable future. There's a lot of TMS clinics around here and most TMS clinics rely on internal referrals to be successful. I find TMS boring and don't really have an interest in overseeing these operations myself though would like to be able to offer it. There are several things I'm much more interested in pursuing over the next yr.

 

[clausewitz2]

I've already increased my hours. The under 15hrs is averaged out over the whole year and things picked up a lot in the latter part of the year (so I've done over 20hrs many weeks in recent months). Though my clinical practice has slowed down a bit recently. I hope to surpass my previous employed salary, if not next yr, then the yr after. I'm very selective about pts I take on and also forensic cases. Have turned down some high profile cases because I just had a bad feeling about them.


Not for the forseeable future. There's a lot of TMS clinics around here and most TMS clinics rely on internal referrals to be successful. I find TMS boring and don't really have an interest in overseeing these operations myself though would like to be able to offer it. There are several things I'm much more interested in pursuing over the next yr.

People where I trained used to make fun of ECT "fellowships" as fellowships in Clinical Button-Pressing, but that seems to fit TMS even better.

 

[psychemdoc]

It's coming to the end of my first year of private practice! I had low expectations. I was so burnt out from my last job I really didn't have it in me to put in a lot of effort to starting and growing a practice. I was hoping to make over $200k my first year after expenses, and I've brought in a little under $310k after expenses. I've probably averaged under 15 hours per week over the course of the past 12 months. I was working well over 40hrs a week in average in academics (?maybe 60), much of it uncompensated. So 1/4 of the work for 3/4 of the pay I would say is pretty good.

The above figures include forensic work, consulting, and chart reviews. If it was just clinical work seeing patients it would be a lot lower. That said, I have not put much effort into marketing, networking etc at this point in time. I have a relatively small number of physicians and psychologists who have referred the bulk of patients I've seen. I'm on the referral lists for the 3 major academic centers in the vicinity.

It can be stressful sometimes dealing with some challenging patients. That is true in any setting but it's easier to feel unsupported and that your own reputation and brand is on the line as a solo practitioners. It's also been really wonderful to see patients who were really unwell now doing really well and provide them with the high level of care I wish more pts had access to.

I do miss some of the zebras I had in academics. However I still do some case consultation to the residents and attendings for weird cases and also get to do some interesting chart reviews and forensic cases!

When I started pp I think I felt a little uncomfortable about how much I charged and about my worth. Now having dealt with some of the BS that comes with both clinical and forensic work, I feel I am worth every penny. We have to contain a lot of powerful emotions, expose ourselves repeatedly to traumatic materials, manage the transference enactments of patients and their relatives, and manage risk. All of that puts a premium on this kind of work. I'm also able to provide expert opinion chart reviews to minimum wage workers through one of my contracts, and treatment to a highly marginalized pt population through my pp with another. All of which is highly compensated.

My plans for the next year are to grow my clinical practice, and branch out into some other non clinical areas I've really wanted to pursue but haven't made the time for. I have 3 things I would like to do (all psych-adjacent). I never in a million years thought I would end up doing private practice. Now I think it is where I belong and what I was meant to do.

Awesome numbers! Very cool success story so far.

 

[splik]

It's been 2 years since I started my PP and I'm basically more than full at this point! It's a good problem to have though I'm a bit stressed with trying to fit people in and organization (and behind on notes!) I do a mix of clinical care, forensic work, 2nd opinion chart reviews, and consulting (e.g. coding/documentation, risk management, case consultation, private practice). My earnings before expenses were about 270k from Jan-Aug (expenses about 15k) which would bring me to an estimated 400k for the year if things continue this way. 15 patient hours/wk was my aim. I had been a bit selective with patients and have very few general psych type pts.

I do feel a little overwhelmed at times but I am working way less than I was in academics but it will probably take me another year to be making similar or more for total compensation. Quite happy with the diversity of my work and getting very interesting cases. I was worried that I wouldn't be able to get the super interesting cases you get in academics but if you're an expert you still can consult on zebras and my referral sources include several academic centers. I also continue to do some teaching so I feel like I'm still getting some of the positives of academics without all the BS.

Now things are bit more established, I'm going to do a new website and start preparing for phase 2 of my pp! and maybe get a much-needed assistant!

 

[smalltownpsych]

It's been 2 years since I started my PP and I'm basically more than full at this point! It's a good problem to have though I'm a bit stressed with trying to fit people in and organization (and behind on notes!) I do a mix of clinical care, forensic work, 2nd opinion chart reviews, and consulting (e.g. coding/documentation, risk management, case consultation, private practice). My earnings before expenses were about 270k from Jan-Aug (expenses about 15k) which would bring me to an estimated 400k for the year if things continue this way. 15 patient hours/wk was my aim. I had been a bit selective with patients and have very few general psych type pts.

I do feel a little overwhelmed at times but I am working way less than I was in academics but it will probably take me another year to be making similar or more for total compensation. Quite happy with the diversity of my work and getting very interesting cases. I was worried that I wouldn't be able to get the super interesting cases you get in academics but if you're an expert you still can consult on zebras and my referral sources include several academic centers. I also continue to do some teaching so I feel like I'm still getting some of the positives of academics without all the BS.

Now things are bit more established, I'm going to do a new website and start preparing for phase 2 of my pp! and maybe get a much-needed assistant!

As I glance through this thread and think about my own experiences over the last couple of years, what strikes me is that building a private practice is a slow and challenging process. Good luck with the assistant, that can be a great help, but also more work. My goal was never to be solo so I started with an assistant and hiring some people pretty quickly. I sometimes look at how much work I do and how much more I could make if I was doing solo and question the choices from a financial sense, but I am also doing what I love and building something that might soon tip the scales to where I am making more than I would solo or in a good salaried job.

 

[MedMan80]

It's been 2 years since I started my PP and I'm basically more than full at this point! It's a good problem to have though I'm a bit stressed with trying to fit people in and organization (and behind on notes!) I do a mix of clinical care, forensic work, 2nd opinion chart reviews, and consulting (e.g. coding/documentation, risk management, case consultation, private practice). My earnings before expenses were about 270k from Jan-Aug (expenses about 15k) which would bring me to an estimated 400k for the year if things continue this way. 15 patient hours/wk was my aim. I had been a bit selective with patients and have very few general psych type pts.

I do feel a little overwhelmed at times but I am working way less than I was in academics but it will probably take me another year to be making similar or more for total compensation. Quite happy with the diversity of my work and getting very interesting cases. I was worried that I wouldn't be able to get the super interesting cases you get in academics but if you're an expert you still can consult on zebras and my referral sources include several academic centers. I also continue to do some teaching so I feel like I'm still getting some of the positives of academics without all the BS.

Now things are bit more established, I'm going to do a new website and start preparing for phase 2 of my pp! and maybe get a much-needed assistant!

Thanks for the update Splik, helps reduce my own anxiety venturing on my own really soon 😉

 

[splik]

Update
After 2.5 years in practice, practice is thriving. I have more patients than I need and continue to do a mix of pp, forensics, consulting on clinical documentation integrity, risk management, and 2nd opinion chart reviews. Over the past 12 months, gross income was over 500k and expenses were a little over 25k. I do about 20-25 hours a week (clinical is usually 15-20 or less). I am very fortunate to still get a lot of patient requests (since not too many patient do what I do) however, I do think attrition has been greater over the past 6 months with the economy. Have had patients lose jobs and/or insurance, or want to cut back on sessions for financial reasons etc. Since most of my patients see me multiple times a month that means: a) more cost for them and b) leaves a hole in schedule if patients who were doing twice weekly visits drop out of treatment. I do offer some sliding scale but only for patients who are committed to regular treatment (e.g. once a week or more). I have got behind on returning new patient requests. I also discharge patients from my practice if they don't need regular care anymore to f/u with PCP.

Getting lots of interesting forensic cases too, decline quite a bit of forensic work because I have too many cases (also a lot of requests are just dumb or the time frame is too tight).

I did get someone to revamp my website which was almost 10yrs old. Still need to bring on an assistant. Would love to get some therapy groups up and running. There's a few other things I want to expand to but I have enough on my plate right now.

 

[Cath Up]

As someone who plans to create a small private practice in the next several years, this thread is much appreciated- thank you for it.

I personally would like to make sure to do some pro bono work in a private practice, but worry that the financial disincentive and 250k loans will cause me to do less of that than I would have planned. Do you find that to be a conflict for yourself with your sliding scale patients and if so how do you navigate it? I don't want to set myself up to become "slippin' jimmy."

If you did take insurance from your clinical population- how different do you think your workload, income, frustration would be?

 

[splik]

As someone who plans to create a small private practice in the next several years, this thread is much appreciated- thank you for it.

I personally would like to make sure to do some pro bono work in a private practice, but worry that the financial disincentive and 250k loans will cause me to do less of that than I would have planned. Do you find that to be a conflict for yourself with your sliding scale patients and if so how do you navigate it? I don't want to set myself up to become "slippin' jimmy."

If you did take insurance from your clinical population- how different do you think your workload, income, frustration would be?

I tried doing some pro bono work to begin with and it was a disaster. The patients would no show, cancel at the last minute, or want to reschedule at the last minute. I might have had bad luck but I no longer offer pro bono. Also, it is usually the most entitled patients who ask for pro bono. And then there are people who take advantage - one pt's mom asked for low bono - turned out both the parents were lawyers and could afford full freight.

Now I offer a sliding scale only to patients who have paid for the initial consultation and are motivated for ongoing therapy. The patients are very appreciative because they know what the full fee is. I am less likely to do this for patients using their OON benefits and instead help them get a network gap exception which in some cases results in them getting 100% (or more!) back from insurance.

I also do some community psych through my PP serving a very marginalized population. I accept one EAP but no insurances. I provide 2nd opinion chart reviews to people who have it as an employer benefit which includes minimum wage workers.

There are many way to support a wider population than just doing pro bono. I think it is unfortunate that most psychiatrists no longer do pro bono (and fewer seem to do sliding scale these days) but unfortunately people take advantage or don't value your time and services if they aren't paying for it. I do think we should all try to expand care - that could be doing a bit of community psych, collaborative care, ED shifts, corrections, accepting medicare or tricare, doing sliding scale, doing immigration evals, teaching med students or residents, offering reduced rates to med students/residents. We can find a way to make this work while also making more than enough.

 

[clozareal]

As someone who plans to create a small private practice in the next several years, this thread is much appreciated- thank you for it.

I personally would like to make sure to do some pro bono work in a private practice, but worry that the financial disincentive and 250k loans will cause me to do less of that than I would have planned. Do you find that to be a conflict for yourself with your sliding scale patients and if so how do you navigate it? I don't want to set myself up to become "slippin' jimmy."

If you did take insurance from your clinical population- how different do you think your workload, income, frustration would be?

I’d recommend holding off on offering sliding scale or pro bono work until you’re more established and financially secure—whether that means paying down debt, saving for a home, or simply building a cushion. It’s important to feel grounded before giving your time away.

Money is fungible, so offering someone a reduced rate during a slot that could be full fee is effectively a financial gift. I only offer sliding scale to patients I’ve been working with for a while who’ve shown strong commitment to treatment.

In my experience, those who bring up sliding scale early—like during the phone screen—often require more time and energy. Some are shopping around based on cost rather than value and that leads to me not feeling good at times. The main benefit I get from offering reduced fees is feeling good about myself and my values. To be worth it, that feeling has to outweigh the lost income.

 

[Merovinge]

I tried doing some pro bono work to begin with and it was a disaster. The patients would no show, cancel at the last minute, or want to reschedule at the last minute. I might have had bad luck but I no longer offer pro bono. Also, it is usually the most entitled patients who ask for pro bono. And then there are people who take advantage - one pt's mom asked for low bono - turned out both the parents were lawyers and could afford full freight.

Now I offer a sliding scale only to patients who have paid for the initial consultation and are motivated for ongoing therapy. The patients are very appreciative because they know what the full fee is. I am less likely to do this for patients using their OON benefits and instead help them get a network gap exception which in some cases results in them getting 100% (or more!) back from insurance.

I also do some community psych through my PP serving a very marginalized population. I accept one EAP but no insurances. I provide 2nd opinion chart reviews to people who have it as an employer benefit which includes minimum wage workers.

There are many way to support a wider population than just doing pro bono. I think it is unfortunate that most psychiatrists no longer do pro bono (and fewer seem to do sliding scale these days) but unfortunately people take advantage or don't value your time and services if they aren't paying for it. I do think we should all try to expand care - that could be doing a bit of community psych, collaborative care, ED shifts, corrections, accepting medicare or tricare, doing sliding scale, doing immigration evals, teaching med students or residents, offering reduced rates to med students/residents. We can find a way to make this work while also making more than enough.

I agree. One other reasonable alternative if your job doesn't support piecemealing things easily is donating money to causes you support. If you are a W2 worker with a non-compete, get some of that good feeling of helping others by donating some money. Bunch it if you can to get a tax break. There are so many mental health and general health care organizations worthy of funding.

 

[Cath Up]

I tried doing some pro bono work to begin with and it was a disaster. The patients would no show, cancel at the last minute, or want to reschedule at the last minute. I might have had bad luck but I no longer offer pro bono. Also, it is usually the most entitled patients who ask for pro bono. And then there are people who take advantage - one pt's mom asked for low bono - turned out both the parents were lawyers and could afford full freight.

Now I offer a sliding scale only to patients who have paid for the initial consultation and are motivated for ongoing therapy. The patients are very appreciative because they know what the full fee is. I am less likely to do this for patients using their OON benefits and instead help them get a network gap exception which in some cases results in them getting 100% (or more!) back from insurance.

I also do some community psych through my PP serving a very marginalized population. I accept one EAP but no insurances. I provide 2nd opinion chart reviews to people who have it as an employer benefit which includes minimum wage workers.

There are many way to support a wider population than just doing pro bono. I think it is unfortunate that most psychiatrists no longer do pro bono (and fewer seem to do sliding scale these days) but unfortunately people take advantage or don't value your time and services if they aren't paying for it. I do think we should all try to expand care - that could be doing a bit of community psych, collaborative care, ED shifts, corrections, accepting medicare or tricare, doing sliding scale, doing immigration evals, teaching med students or residents, offering reduced rates to med students/residents. We can find a way to make this work while also making more than enough.

That all makes a ton of sense. Thank you all for the perspective.

 

[vanfanal]

Update
After 2.5 years in practice, practice is thriving. I have more patients than I need and continue to do a mix of pp, forensics, consulting on clinical documentation integrity, risk management, and 2nd opinion chart reviews. Over the past 12 months, gross income was over 500k and expenses were a little over 25k. I do about 20-25 hours a week (clinical is usually 15-20 or less). I am very fortunate to still get a lot of patient requests (since not too many patient do what I do) however, I do think attrition has been greater over the past 6 months with the economy. Have had patients lose jobs and/or insurance, or want to cut back on sessions for financial reasons etc. Since most of my patients see me multiple times a month that means: a) more cost for them and b) leaves a hole in schedule if patients who were doing twice weekly visits drop out of treatment. I do offer some sliding scale but only for patients who are committed to regular treatment (e.g. once a week or more). I have got behind on returning new patient requests. I also discharge patients from my practice if they don't need regular care anymore to f/u with PCP.

Getting lots of interesting forensic cases too, decline quite a bit of forensic work because I have too many cases (also a lot of requests are just dumb or the time frame is too tight).

I did get someone to revamp my website which was almost 10yrs old. Still need to bring on an assistant. Would love to get some therapy groups up and running. There's a few other things I want to expand to but I have enough on my plate right now.

This is great! Congratulations to you for putting something like this together and maximizing your expertise.
Sounds like a lot of your work is niche to your training/experience in forensics which I would assume has a higher hourly rate than gen psych.

What proportion of your time do you think is forensic training-based vs general psych?
Wondering if you or anyone else has ideas on how to establish that level of a PP without a forensics background?

 

[randomdoc1]

I tried doing some pro bono work to begin with and it was a disaster. The patients would no show, cancel at the last minute, or want to reschedule at the last minute. I might have had bad luck but I no longer offer pro bono. Also, it is usually the most entitled patients who ask for pro bono. And then there are people who take advantage - one pt's mom asked for low bono - turned out both the parents were lawyers and could afford full freight.

Now I offer a sliding scale only to patients who have paid for the initial consultation and are motivated for ongoing therapy. The patients are very appreciative because they know what the full fee is. I am less likely to do this for patients using their OON benefits and instead help them get a network gap exception which in some cases results in them getting 100% (or more!) back from insurance.

I also do some community psych through my PP serving a very marginalized population. I accept one EAP but no insurances. I provide 2nd opinion chart reviews to people who have it as an employer benefit which includes minimum wage workers.

There are many way to support a wider population than just doing pro bono. I think it is unfortunate that most psychiatrists no longer do pro bono (and fewer seem to do sliding scale these days) but unfortunately people take advantage or don't value your time and services if they aren't paying for it. I do think we should all try to expand care - that could be doing a bit of community psych, collaborative care, ED shifts, corrections, accepting medicare or tricare, doing sliding scale, doing immigration evals, teaching med students or residents, offering reduced rates to med students/residents. We can find a way to make this work while also making more than enough.

so much this. many patients whether of low SES or high SES, do not appreciate whether it's pro bono, low bono or reasonable price bono. What I love about PP is you can take the time to find a population that is motivated and have a healthy working relationship. That's my only criteria to get care at my office. Be an active participant in your care and let's have a healthy relationship. It's totally feasible to be comfortable AND expand access to care. My state, the medicaid rates are almost comparable to commercial rates. For those not poor enough for Medicaid but they don't have employer sponsored insurance, there is Obama care that is income adjusted. There is a way!

 

[Merovinge]

This is great! Congratulations to you for putting something like this together and maximizing your expertise.
Sounds like a lot of your work is niche to your training/experience in forensics which I would assume has a higher hourly rate than gen psych.

What proportion of your time do you think is forensic training-based vs general psych?
Wondering if you or anyone else has ideas on how to establish that level of a PP without a forensics background?

Be extremely effin knowledgeable about psychiatry or at least sub domains of psychiatry. If you have seen Spilk's posts on SDN, you know it's far more than a forensic fellowship he/she is offering. I would hire them for myself/my family in a heartbeat based on their incredible domain expertise. Whilst I would like any psychiatrist seeing myself/my family to have good social skills, what I really want them to have is incredible command of the science of mental health.

The people who do really well in PP either have at least 1 of the following: great soft skills, sell pseudoscience/controlled subs, excellent psychiatric knowledge.

 

[randomdoc1]

The people who do really well in PP either have at least 1 of the following: great soft skills, sell pseudoscience/controlled subs, excellent psychiatric knowledge.

People who do really well in the MH work force in general. As an employer now....if you have none of these, I find that profile struggling in the job market. Often going from job to job to job (or miserable at the same job), not acknowledging the matter is originating from within. Very philosophical lol. The other end of that argument is if one has all those capabilities, it makes you nearly unstoppable.

Just had a zoom meeting with a psych program director and we had a professional difference of opinions. She said something along the lines of the quote above applying primarily to PP. I said "name one place in this world that does not have a revenue cycle, profit loss margin, and is immune from the laws of economics." It was met with silence. I thought so. If the day comes that some one can do that, I'm happy to call myself an idiot. And as a bonus will throw in a dance in a chicken suit for them to the song of their choice.

 

[splik]

This is great! Congratulations to you for putting something like this together and maximizing your expertise.
Sounds like a lot of your work is niche to your training/experience in forensics which I would assume has a higher hourly rate than gen psych.

What proportion of your time do you think is forensic training-based vs general psych?
Wondering if you or anyone else has ideas on how to establish that level of a PP without a forensics background?

My practice is focused on my niche specialty, but that is separate from forensics. In addition to my clinical practice, about 25-30% of my time is spent doing forensics. The hourly rate is overall similar to my clinical work, and for many publicly funded cases it is actually lower than my clinical rate. I do those cases because I find it very interesting.

I do very little general psych though (maybe a few hours a month) as discussed in previous posts. Not a fan of general adult outpatient psych.

Having the diversity of doing forensics and consulting in addition to clinical work was certainly helpful in bringing in income from multiple revenue sources while I was building up my clinical practice, but I could just do clinical work if I wanted especially at this point. But definitely in my first year I would have struggled more financially if I wasn't doing non-clinical work as well.

 

[MedMan80]

Update
After 2.5 years in practice, practice is thriving. I have more patients than I need and continue to do a mix of pp, forensics, consulting on clinical documentation integrity, risk management, and 2nd opinion chart reviews. Over the past 12 months, gross income was over 500k and expenses were a little over 25k. I do about 20-25 hours a week (clinical is usually 15-20 or less). I am very fortunate to still get a lot of patient requests (since not too many patient do what I do) however, I do think attrition has been greater over the past 6 months with the economy. Have had patients lose jobs and/or insurance, or want to cut back on sessions for financial reasons etc. Since most of my patients see me multiple times a month that means: a) more cost for them and b) leaves a hole in schedule if patients who were doing twice weekly visits drop out of treatment. I do offer some sliding scale but only for patients who are committed to regular treatment (e.g. once a week or more). I have got behind on returning new patient requests. I also discharge patients from my practice if they don't need regular care anymore to f/u with PCP.

Getting lots of interesting forensic cases too, decline quite a bit of forensic work because I have too many cases (also a lot of requests are just dumb or the time frame is too tight).

I did get someone to revamp my website which was almost 10yrs old. Still need to bring on an assistant. Would love to get some therapy groups up and running. There's a few other things I want to expand to but I have enough on my plate right now.

It might be my ADHD, but is that 500K in addition to your other side hustles?