Your concerns are warranted. There is a possibility over the next few years I'll discover I like a certain type of practice more than outpatient. This is a possibility. I could be content to maybe happy in a lot of specialties, even those outside of psychiatry. However, I look to the smaller details that I feel can predict longevity of a type of practice, and for me that is private practice. Michaelrack also points out the viable option of doing both.
Here is a random collection in no clear organization of thoughts I've had shaping my desire for private practice.
-colleagues. When you aren't the boss doing the hiring and firing you will be stuck with people who are lazy and incompetent. In private practice, as Whopper has aluded to the practice he might take over, you can get a staff that you change your mind set of wanting to work for you, but you wanting to work for them and give an excellent working environment. I have seen in different businesses the difference the world can be when you work with people you enjoy and want good things for. That significantly contributes to wanting to go to work long after the excitement and buzz of the work itself is gone. Life is about people. When you are employed there is less of a sense of permanency and it filters into the quality of work relations.
-Ownership. In private practice I can take ownership of my patients. I don't have to worry about others cross covering and tinkering with the ultimate medication goals or not being aware of the nuisances of a patient and setting treatment back. I will be on call 24/7 but I can handle that persistent low level stress. I also like that likelihood of being called after hours is much less than if I were in a group practice and hammered with calls/admission/refills for 24hrs straight every few days. No thanks. I'd like to spread it out which a solo private practice can do.
-Money. Cash only. I will get to choose what my value is – and not the insurance companies. I will get to choose who gets charity care and not the government or insurance companies. I can choose who gets reduced rates without worrying about which insurance contracts I just violated. I don't need to worry about over/underbilling with the government and being imprisoned as a result of it or being fined exorbitantly. It is rewarding to me to know I'm not getting screwed against my will.
-Less meetings. I have seen academic medicine from a resident perspective and observing my own schedule and that of attendings, it is filled with constant meetings. What a waste. No thanks.
-Ingenuity/technology. I can implement telepsychiatry if I desire. I can choose my own EMR or home design if I wish. I can have my own pixis machine and formulary for dispensing. I can implement email, apps, phones, websites, and other medias as much or as little as I choose without having to have meetings and meetings and discussions with institutional IT people only to get a run around of bureaucracy. I won't be limited by senior partners who have technological deficiencies because of their age and refusal to enter the technological era.
-Office. It will be designed by me. The decorations, ambiance, and overall feel will be set to my specifications rather than what the hospital is willing to give or furnish.
-Health insurance. I can choose what works for me and my future family best. I can also use HSA's to my advantage for establishing with cash only PCPs. I won't be limited by the few options an employer offers.
-Soft benefits of tax deductions for vehicles and other things.
-As much or as little vacation as I require limited by the very obvious consequences to the practice.
-Beating the rush. As the healthcare system implodes under the weight of being an unfunded mandate of nation collapsing proportions I will have already established myself in the cash/private practice arena. Most, not all physicians, will find themselves reversing the trend of being employed physicians and struggling to hang their own shingle.
-Pride/Quality. Pride of ownership. There is pride in preserving the difference in quality of practice and education when compared to midlevels. The government and insurance companies care nothing for this. This is partly related in being able to spend the time with patients, which I will do even at the cost of a lower income. However, limited overhead and efficiency in other arenas can compensate this drop. I don't have to worry about meeting quotas, I need only to practice. I won't have to label a borderline as a bipolar for the sake of getting paid. I won't have to be constricted to the DSM for diagnosing to simply get paid. I can focus on the patient and in the rare occasions where a V code or something else is more appropriate I can give that diagnosis. I will also fight harder for my patients because they are MY PATIENTS, not the universities, not the clinics, not community mental health centers, but mine.
-Investment. I can invest resources how I choose. Rather than attending a committee or drafting proposals or begging for certain things I can simply do it by taking a cut in my take home pay. If I want to purchase a TMS, I can do it. I want to buy the latest ECT machine I can do it.
-Speaking. If I want to be a speaker I can do it, and will be limited only by my conscious and not arbitrary rules of an institution.
-Not alone. Private practice isn't a lonely endeavor anymore. We have places like SDN, and even better SERMO where you can do ‘curbside' consults with other colleagues to point one in the direction for literature searches or even direct treatment.
