Private Practice straight out of residency

[moto_za]

Hi All, just wondering what peoples thoughts were about starting a cash only private practice straight out of residency? I initially was going to accept and work in an outpatient clinic full time after residency but now thinking of not accepting that job and starting my own practice and moonlighting on the side while building the business. Any thoughts from people who have experienced doing this or thinking about this as well?

Another thought I had was to do the full time outpatient clinic and slowly build the private practice but not sure if realistically will have time to do both.

Thanks for any advice or help.

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[B52slinger]

Hi All, just wondering what peoples thoughts were about starting a cash only private practice straight out of residency? I initially was going to accept and work in an outpatient clinic full time after residency but now thinking of not accepting that job and starting my own practice and moonlighting on the side while building the business. Any thoughts from people who have experienced doing this or thinking about this as well?

Another thought I had was to do the full time outpatient clinic and slowly build the private practice but not sure if realistically will have time to do both.

Thanks for any advice or help.

I was considering it but after speaking with some attendings it seems like a good idea to just start it on the side as you likely won't fill very quickly straight out of residency (unless you're in a great area). I'll be working full-time inpatient + telepsych to start.

 

[Celexa]

I know plenty of people who did this, as long as you have a moonlighting gig that meets your financial needs if that's what you want to do I don't see why you shouldn't go for it.

 

[Merovinge]

I would recommend working with a senior OP psychiatrist on an 80/20 style split for a few years if possible. Provided they are willing to do this without a non-compete and are actually interested in mentoring. It's not to say you can't do it yourself, but paying a low 6 figure amount over a few years is easily worth the investment for learning the ropes. There is so much about PP that is not taught in residency training.

 

[Sushirolls]

And most of that you need to just dive in and learn. Skip being mentored.
Do it.
Start your own thread detailing your journey and ask your questions of help in that thread as they pop up.
Read my practice thread once, twice, thrice and have that as a foundation to spring from.
Also look at @splik thread 'private practice musings' and review the posts by @randomdoc1 @trophyhusband

There are several others I'm forgetting who have posts worthy of reviewing. If that's you, please post below 'yo, sushi, you forgot me'

Look, ARNPs are doing this fresh off their diploma mills. You can do it too. I know CCF resident years ago who had side private practice as PGY-III. This isn't rocket science.

 

[smalltownpsych]

And most of that you need to just dive in and learn. Skip being mentored.
Do it.
Start your own thread detailing your journey and ask your questions of help in that thread as they pop up.
Read my practice thread once, twice, thrice and have that as a foundation to spring from.
Also look at @splik thread 'private practice musings' and review the posts by @randomdoc1 @trophyhusband

There are several others I'm forgetting who have posts worthy of reviewing. If that's you, please post below 'yo, sushi, you forget me'

Look, ARNPs are doing this fresh off their diploma mills. You can do it too. I know CCF resident years ago who had side private practice as PGY-III. This isn't rocket science.

Completely agree with this post. Also, I am assuming that coming out of residency, your income is relatively low so it is probably easier to make that start now than a few years down the road when income is likely higher and spending has typically matched that higher income. I am one year in to my own private practice scheme and my only regret is that I didn’t do it sooner. That first year was scary because my income dropped from 140k to about 50k and went into a bit of debt, but I had just enough headroom to weather that and now am actually paying the debt back. I am also doing cash pay and at times, especially early on I have worried about making that choice, but not today.

I also took a higher overhead approach than some as I felt that made sense with the patients I was targeting and what I wanted to create so I started with a little extra office space and after a few months hired a full-time admin person and now have a couple of part-time therapy interns that can do mentoring and/or therapy for a few of my higher need patients who have family able to pay for the extra support needed.

Part of my philosophy is “if you build it they will come” with a little “go big or go home” and some of it is to have some flexibility built in to my plan since I still am not quite sure what I want to do when I grow up.

 

[Stagg737]

And most of that you need to just dive in and learn. Skip being mentored.
Do it.
Start your own thread detailing your journey and ask your questions of help in that thread as they pop up.
Read my practice thread once, twice, thrice and have that as a foundation to spring from.
Also look at @splik thread 'private practice musings' and review the posts by @randomdoc1 @trophyhusband

There are several others I'm forgetting who have posts worthy of reviewing. If that's you, please post below 'yo, sushi, you forgot me'

Look, ARNPs are doing this fresh off their diploma mills. You can do it too. I know CCF resident years ago who had side private practice as PGY-III. This isn't rocket science.

@clausewitz2 Also shared their start-up info in that thread, but was more of a hybrid set up. Same with @Jules A , but they are an NP, so slightly different pathway but still relevant in terms of starting up a PP.

Hi All, just wondering what peoples thoughts were about starting a cash only private practice straight out of residency? I initially was going to accept and work in an outpatient clinic full time after residency but now thinking of not accepting that job and starting my own practice and moonlighting on the side while building the business. Any thoughts from people who have experienced doing this or thinking about this as well?

Another thought I had was to do the full time outpatient clinic and slowly build the private practice but not sure if realistically will have time to do both.

Thanks for any advice or help.

Is there anything stopping you from taking a part-time employed outpatient position while you set up your PP on the side? Even working just 3 days a week employed should still get you a 6 figure salary while you build up your PP on those other 2 days.

 

[psychemdoc]

Pretty much everyone is encouraging you to do it in various capacities and as someone who’s not a psychiatrist but I thoroughly enjoy reading these I will also recommend you follow through on this and keep a thread with your updates like all the ones that sushi and stag mentioned.

 

[whopper]

Mentoring-a good idea but only if the mentor is good. If the "mentor" sucks it might not be worth it.

 

[Merovinge]

Mentoring-a good idea but only if the mentor is good. If the "mentor" sucks it might not be worth it.

I agree. I think on the whole the average psychiatrist is a poor candidate to go immediately into solo PP. If someone had a longstanding entrepreneurial bent and very strong clinical knowledge it's absolutely reasonable but finding a good mentor is probably ideally for the majority.

 

[whopper]

I've seen no private practice doctor ever be a good mentor. That doesn't mean they're not out there. I've seen great private practice doctors. Reason why none of them are good mentors are it makes them no money and the more patients they see the more money they make. They will make nothing on mentoring you.

Add to this, most doctors who enter private practice aren't the "I want to be the best doctor I can be type" and are in it for the money. While of course there will be some who enter private practice who want to learn they're not in an environment that incentives it or draws that type of crowd.

Again a reason why I recommend people do academia at least a few years straight out of residency. After learning from it then make a private practice if you want. Top off and plateau on skills that still need brushing up.


I can see such a practice where the doctors are collegial, scholarly, and helpful, but so far I haven't seen it. As I've said before several psychiatrists aren't any good. You might find good ones but that doesn't mean they want to teach. The practice I'm currently in has a rep of being the best in the city and most of my colleagues are former professors but guess what? None of them like to discuss cases in a scholarly manner. Whenever someone contacts our practice I've been the only one willing to see people who want mentoring such as a student who wants to do a rotation. I've seen literally no private practice doctor in this entire city that wants to teach unless a pharm company is paying them.

Another thing is I've had people I've been willing to mentor turn out to be total a-holes. It really killed my desire to continue teaching in a manner that curbs my income. Taking in someone to mentor slows me down. So I am making a real sacrifice by letting someone do a rotation. While several of the people I've mentored have been nice and gave me the emotional high of teaching some turn out to be real a-holes and I only realized it afterwards and I gave them good marks. Someone I "mentored" was later kicked out of of our own practice. She started fights with patients and other providers. She, however during her rotation with me kept her mouth shut and was polite, although very very very quiet. In hindsight I came to realize she was quiet cause she knew she was a selfish prick a-hole and had she said what she was thinking I likely would've failed her. I was her last rotation, she joins the practice, she shows her true colors. Within the first week she worked at our place literally started fights daily with the staff, and started insulting patients who weren't her own in the waiting room. After a few weeks of this she was asked to permanently leave the practice. I haven't been willing to take in someone to mentor ever since.

 

[Celexa]

I've seen no private practice doctor ever be a good mentor. That doesn't mean they're not out there. I've seen great private practice doctors. Reason why none of them are good mentors are it makes them no money and the more patients they see the more money they make. They will make nothing on mentoring you.

Add to this, most doctors who enter private practice aren't the "I want to be the best doctor I can be type" and are in it for the money. While of course there will be some who enter private practice who want to learn they're not in an environment that incentives it or draws that type of crowd.

Again a reason why I recommend people do academia at least a few years straight out of residency. After learning from it then make a private practice if you want. Top off and plateau on skills that still need brushing up.


I can see such a practice where the doctors are collegial, scholarly, and helpful, but so far I haven't seen it. As I've said before several psychiatrists aren't any good. You might find good ones but that doesn't mean they want to teach. The practice I'm currently in has a rep of being the best in the city and most of my colleagues are former professors but guess what? None of them like to discuss cases in a scholarly manner. Whenever someone contacts our practice I've been the only one willing to see people who want mentoring such as a student who wants to do a rotation. I've seen literally no private practice doctor in this entire city that wants to teach unless a pharm company is paying them.

Another thing is I've had people I've been willing to mentor turn out to be total a-holes. It really killed my desire to continue teaching in a manner that curbs my income. Taking in someone to mentor slows me down. So I am making a real sacrifice by letting someone do a rotation. While several of the people I've mentored have been nice and gave me the emotional high of teaching some turn out to be real a-holes and I only realized it afterwards and I gave them good marks. Someone I "mentored" was later kicked out of of our own practice. She started fights with patients and other providers. She, however during her rotation with me kept her mouth shut and was polite, although very very very quiet. In hindsight I came to realize she was quiet cause she knew she was a selfish prick a-hole and had she said what she was thinking I likely would've failed her. I was her last rotation, she joins the practice, she shows her true colors. Within the first week she worked at our place literally started fights daily with the staff, and started insulting patients who weren't her own in the waiting room. After a few weeks of this she was asked to permanently leave the practice. I haven't been willing to take in someone to mentor ever since.

I find the idea of a private pracrice mentor (in the sense people have academic mentors, longitudinally guiding you over fairly long periods of time) sort of odd. On the other hand, a few times during residency we had lecturers who were in private pracrice and at least once instead of talking about the clinical topic at hand, one of them spoke happily for an hour about the mechanics of their private practice. It was one of the most useful hours of didactics we ever had. Similarly, this forum has a wealth of helpful information. I credit a combination of these things with why I am planning to start a niche private practice in addition to my primary academic gig.

I could definitely see going to lunch or coffee with someone in successful local private pracrice and talking about the process. Long term formal "mentorship"? Eh.

 

[whopper]

Add to it what if the "mentor" is a bad doctor? This will mirror the relationship between Louie and Lestat in Interview with the Vampire. If you watched the movie it didn't emphasize this as much but it was in there. The book very much emphasized that Louie was being manipulated by a parasitic mentor. Louie didn't know the limits of his abilities. Lestat manipulated that naivety. So for example Louie (as he described himself, later novels showed he was heavily biased and Lestat not as bad as Louie may have made him out to be), when he becomes a vampire is told the only way to stay alive was to kill humans and consume their live blood. After Louie becomes accustomed to killing only then does Lestat tell him they could also consume the blood of animals.

I've seen several doctors in private situations not let their underling physicians know how it really works. E.g. the head doctor might be raking in a lot more money than his underlings would feel comfortable making for him. In any organization where you work there will be a trade-off but it should be fair. E.g. if you're paying 30% into the organization but they're doing stuff for you such as billing, hiring a receptionist etc that's about a fair amount. Be very wary if its higher than this. That's about what you'd pay anyway had you been on your own.

Such a fair organization would be transparent, explain how it works to you and not keep you in the dark. They might even make you a partner.

Some real-life examples of not being fair? They want you to do a call, a call where you will be called many times in the night for only $100 a night. Seriously. WTF. I've seen people actually sign up for this. Then they bring up you need to be a team player all the while the head guy is making over a million a year and he never does this bull$hit himself. Or you're paid about $200K a year when you're really bringing more than twice this. Also you notice ways to practice better not only clinically but monetarily and they won't let you do it.

I'm the only guy I know in my city that worked privately that was willing to mentor up until about a year ago, but that desire was killed as I mentioned above. I still do it, but in a manner where I'm compensated for it-I got NPs. I'm their mentor and I make money off it. Also I only take NPs if I think they're good. The ones I got now are better than most doctors I know.

 

[Bartelby]

I think people are right to hone in on "mentorship" out of residency. In my first job I worked under an amazing medical director. I rarely needed help, but it was very comforting to have someone to go to with questions when needed. It was also great to have someone who specifically knew all the local resources, internal politics, standard practices, etc. You can generally figure this stuff out on your own, but once you are out in the attending world it is good to have someone to reality-check the difficult situations at least for a couple of years.

With that said, you can create that on your own in private practice. Find or create a peer supervision group. You can get support, bounce ideas off members of the group, and make sure you are not going off the rails when you encounter tricky new situations. If one or more members of the group are senior that's great, but unnecessary. We are all highly trained coming out of residency, and even if these are other recent grads I am confident you will collectively meet any challenge of new attendinghood.

 

[medium rare]

Agree with others that it is completely doable and, if private practice is what you want to do, I wouldn’t put off starting one.

 

[zenmedic]

How can you moonlight while building up a cash only pp? From my understanding, if you're cash only you've opted out of insurance, thereby preventing you from pretty much working any inpatient (or any insurance based) job.

 

[trophyhusband]

@clausewitz2 Also shared their start-up info in that thread, but was more of a hybrid set up. Same with @Jules A , but they are an NP, so slightly different pathway but still relevant in terms of starting up a PP.



Is there anything stopping you from taking a part-time employed outpatient position while you set up your PP on the side? Even working just 3 days a week employed should still get you a 6 figure salary while you build up your PP on those other 2 days.

I don't think Jules A is an NP but I could be mistaken. Medium Rare is but is very clear and open about it.

 

[splik]

go for it! I definitely would not recommend working for someone else if your goal is your own pp. One of the reasons residents from top programs often have successful cash practices is because they are able to access mentorship, coaching or supervision from volunteer faculty who are in pp and able to help them. If you aren't able to access this, you could just try reaching out to people and offer to take them out to lunch to learn more about the ins and outs of practice. Worst case scenario, there are a lot of people who will help you with thinking through setting up a practice for a fee. For some people it will be well worth paying for it.

As mentioned above, it isn't rocket science. although employment is becoming increasingly common, psychiatrists have been going into private practice since they escaped the asylum in the early 20th century. still, It can feel a bit daunting to start your own practice. One thing that helped me, was knowing how many psychiatrists there are out there who are totally clueless about running a practice or otherwise incompetent who seem to be doing quite well for themselves. That gave me all the confidence I needed to plough ahead!

How can you moonlight while building up a cash only pp? From my understanding, if you're cash only you've opted out of insurance, thereby preventing you from pretty much working any inpatient (or any insurance based) job.

You haven't opted out of insurance, you just dont accept insurance in your pp if cash only. plenty of people moonlight or have full time insurance accepting jobs while having cash practices. There can be some confusion and some patients might still tell you that you show up as in network even though you've told them you're cash only repeatedly, but there is no conflict for the most part. Now, if you opt out of medicare, you won't be able to work any jobs where you need to see medicare patients, but you could not opt out and just not accept medicare in your pp.

 

[VA Hopeful Dr]

How can you moonlight while building up a cash only pp? From my understanding, if you're cash only you've opted out of insurance, thereby preventing you from pretty much working any inpatient (or any insurance based) job.

Only Medicare is all or none.

 

[splik]

Only Medicare is all or none.

and cigna. though I told them to pîss off.

 

[zenmedic]

Thanks @splik and @VA Hopeful Dr ! I was always really confused on that.

 

[FlowRate]

just not accept medicare in your pp.

This ultimately ends up being not accepting people over 60 or who are disabled, right? Since if you're not opted out of medicare you can't charge medicare pts cash?

 

[Sushirolls]

Correct

 

[splik]

This ultimately ends up being not accepting people over 60 or who are disabled, right? Since if you're not opted out of medicare you can't charge medicare pts cash?

65 or who have had SSDI for 2 yrs, or have ALS or have ESRD on dialysis. However 50% of medicare beneficiaries have medicare advantage. If you put your medicare into a managed care plan, it's as if you don't have medicare at all. For example, I see a few kaiser medicare pts and charge them cash. It's really not a big deal unless you end up seeing an original medicare beneficiary and charge them cash. I only ran into this issue once and ended up seeing the pt for free and told them if they wanted to pay for another pt to see me who wouldnt otherwise be able to afford it, then they could.

 

[FlowRate]

65 or who have had SSDI for 2 yrs, or have ALS or have ESRD on dialysis. However 50% of medicare beneficiaries have medicare advantage. If you put your medicare into a managed care plan, it's as if you don't have medicare at all. For example, I see a few kaiser medicare pts and charge them cash. It's really not a big deal unless you end up seeing an original medicare beneficiary and charge them cash. I only ran into this issue once and ended up seeing the pt for free and told them if they wanted to pay for another pt to see me who wouldnt otherwise be able to afford it, then they could.

Thanks.

Should have clarified in my earlier post when I said 60 I meant to say 60ish as an arbitrary cut point where your patients won't become medicare beneficiaries any time soon.

 

[Sushirolls]

65 or who have had SSDI for 2 yrs, or have ALS or have ESRD on dialysis. However 50% of medicare beneficiaries have medicare advantage. If you put your medicare into a managed care plan, it's as if you don't have medicare at all. For example, I see a few kaiser medicare pts and charge them cash. It's really not a big deal unless you end up seeing an original medicare beneficiary and charge them cash. I only ran into this issue once and ended up seeing the pt for free and told them if they wanted to pay for another pt to see me who wouldnt otherwise be able to afford it, then they could.

This is the head scratcher I've had.
Can we charge the Med Adv plan people cash, or does that general blanket of Medicare trump everything.
I've been operating under that modus, of no Med Adv either.

 

[Geraltofrivia]

Straight out of residency I would do it after the boards personally. I am planning to start my own soon though