Pulling connections for jobs?

[Stumpyman]

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Rising PGY-4 here. Looking to apply for jobs out in California, but a resident on the other side of the country. As residents we get plenty of recruitment job advertisements but I’ve been told by a few folks that advertised jobs are not worth it and are “being advertised for a reason.” I’ve been told pulling connections is the way to get an “in” into where you want to go. How true is this? I have zero connections to California, and don’t even know which hospitals or clinics to reach out to. Should PGY-4s essentially ignore advertised jobs?

 

[comp1]

Yes, but what kind of job do you want? You don't necessarily need connections, but you do need to have more of an idea of a location than "California" (even if it is indeed the best place to be in general) and you do need to have an idea of the type of job and setting you're looking for. For example, if you want a VA job, you go to usajobs.gov. Most university settings are going to have similar websites. Even smaller hospitals will at least have a HR email address.

 

[Stumpyman]

Yes, but what kind of job do you want? You don't necessarily need connections, but you do need to have more of an idea of a location than "California" (even if it is indeed the best place to be in general) and you do need to have an idea of the type of job and setting you're looking for. For example, if you want a VA job, you go to usajobs.gov. Most university settings are going to have similar websites. Even smaller hospitals will at least have a HR email address.

Mostly looking into Sacramento area and possibly San Diego. I do see a good amount of advertised jobs in both places but it’s really hard to tell what is worth pursuing. Primarily interested in inpatient work but open to outpatient (don’t love the churn model that most clinics have though, seeing over 15 a day for very brief visits; though otherwise I love outpatient more than inpatient). Is there a way to know which hospitals or clinics have a good rep for being good places for psychiatrists to work at?

 

[randomdoc1]

As a psychiatrist turned employer, psychiatry may be in demand, but connections and word of mouth can still make or break your prospects. Coworkers talk. Patients talk. Managers and CEOs talk. They all know each other. We're all human and can be a bunch of gossipy high school girls. You want to have a name that lights up the room. Not the one that breaks out the tumbleweeds. Little answer is an answer. And not a good one. Especially if you have other candidates with glowing references, the ones with the less enthusiastic ones get lost in the shuffle. A psychiatrist will still always have a job. But the good jobs....the competition is real.

 

[splik]

Rising PGY-4 here. Looking to apply for jobs out in California, but a resident on the other side of the country. As residents we get plenty of recruitment job advertisements but I’ve been told by a few folks that advertised jobs are not worth it and are “being advertised for a reason.” I’ve been told pulling connections is the way to get an “in” into where you want to go. How true is this? I have zero connections to California, and don’t even know which hospitals or clinics to reach out to. Should PGY-4s essentially ignore advertised jobs?

That is ridiculous. There is a massive shortage of psychiatrists. Most places need to advertise (and may be required by law or institutional polices to do so!)

I think it is true that the most desirable jobs don't need to use recruiters and some niche ones will use their networks to find the best people, but any academic, federal, state, county, hospital, HMO, or large clinics will need to advertise and/or use recruiters (both internal or external).

 

[randomdoc1]

That is ridiculous. There is a massive shortage of psychiatrists. Most places need to advertise (and may be required by law or institutional polices to do so!)

I think it is true that the most desirable jobs don't need to use recruiters and some niche ones will use their networks to find the best people, but any academic, federal, state, county, hospital, HMO, or large clinics will need to advertise and/or use recruiters (both internal or external).

we may be differing in our tolerance of what kind of job. I find over 95% of psychiatry jobs

💩. I've always been built for PP from day 1 and can never imagine any other setting. And I love being my own boss. I realize my preferences fall into a much narrower range than what most other providers would tolerate though. I know you have also transitioned to PP. Most of my colleagues hate their jobs. Not sure what happened to the formatting there. Like any work force, networking is a huge strength. We're not immune from the basic laws of economics and marketing. I've turned down half the psychiatrist candidates at this office. The hospital systems also send surveys of over 40+ questions to previous employers about provider behavior at last place of employment. I know HR there too and they also turn down their share of applicants. I can most intimately speak of my own practice. We pay over $310 an hour, and I take my time for the right fit. The clinic is in a financially comfortable spot. There's no hurry. We'd be doing great even with no psychiatrist. What I care about is maintaining the brand, mission, and strong referral stream and presence we have in the community. If we thought a challenging patient is tough to work with, try a challenging employee. They truly can ruin your SEO presence, referral stream, crap on employee morale and be a toxic force to the work atmosphere. Especially if they are over confident and arrogant--overestimating what worth they bring. I had a provider actually not bring in much literally and figuratively and patients, providers, and non clinical staff just could not stand him. And he was still so confident he asked for a raise. Eventually a patient filed a lawsuit against him and he quit. Healthy doses of humility and team spirit are a huge strength in any employee in any industry--regardless of how many degrees we have. Our worth and education is in how we conduct ourselves, not the piece of paper we get on graduation.​

 

[randomdoc1]

These are some slides I show residents and concepts I learned that turbo boosted my networking and career prospects. I think she illustrates this beautifully. Things not explicitly said, but really helpful concepts that apply anywhere someone works and how to leave a shining impression to open as many doors as possible. You never know what will open up.

 

[comp1]

Okay, Sacramento's good. Certainly VA jobs available on usajobs.gov (they're under Mather or McClellan), but nothing inpatient at the moment. You can also look at the state prison job, as there are several prisons next to Sacramento. Physician Careers There's a couple of positions at UC Davis, although they look kinda specialized and outpatient. Browse Open Recruitments or Log In - AP Recruit UCD handles all county psychiatrist jobs. In terms of Sierra Vista and Heritage Oaks, they're the local UHS outfits and you have to apply through their site. UHS Careers UHS...always has jobs everywhere, although I think they are 1099's. My personal recommendation outside the VA might be Sutter Center for Psychiatry, which you'd apply for here: Careers at Sutter Health | Sutter Health jobs Signature Healthcare runs the newest hospital "Sacramento Behavioral Healthcare Hospital." It seems to be mostly forensic (although certainly would not require a fellowship) with kind of state hospital overflow focus. You can apply here: Provider Recruitment and Employment | Signature Healthcare

 

[mistafab]

If you're looking for academic jobs, then yes - getting 'pull' from your folks can be important. For non-academic jobs, pull does help but isn't a deal breaker. Postings can be a good start - I would also look at places in the geography you want and reach out directly through their website. i.e. there are not many hospitals in sacramento, you can reach out directly to hospital liaisons at departments you want to work at. Go to their internal postings or career areas to find out if they are hiring. Reach out to their recruitment folks.

 

[docloufan]

These are some slides I show residents and concepts I learned that turbo boosted my networking and career prospects. I think she illustrates this beautifully. Things not explicitly said, but really helpful concepts that apply anywhere someone works and how to leave a shining impression to open as many doors as possible. You never know what will open up.
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Sometimes people, ya know, just want to their job, man.

"Causal" remarks in meeting??? Yes, lets all be robots. What fun. Ridiculous. And don't expect praise for doing my job? That some kind of joke? What leadership school is that from? That ****s ancient.

 

[michaelrack]

Okay, Sacramento's good. Certainly VA jobs available on usajobs.gov (they're under Mather or McClellan), but nothing inpatient at the moment. You can also look at the state prison job, as there are several prisons next to Sacramento. Physician Careers There's a couple of positions at UC Davis, although they look kinda specialized and outpatient. Browse Open Recruitments or Log In - AP Recruit UCD handles all county psychiatrist jobs. In terms of Sierra Vista and Heritage Oaks, they're the local UHS outfits and you have to apply through their site. UHS Careers UHS...always has jobs everywhere, although I think they are 1099's. My personal recommendation outside the VA might be Sutter Center for Psychiatry, which you'd apply for here: Careers at Sutter Health | Sutter Health jobs Signature Healthcare runs the newest hospital "Sacramento Behavioral Healthcare Hospital." It seems to be mostly forensic (although certainly would not require a fellowship) with kind of state hospital overflow focus. You can apply here: Provider Recruitment and Employment | Signature Healthcare

UHS does have some employed psychiatrists , but yes they are predominantly 1099.

 

[FatherPsychiatry]

Rising PGY-4 here. Looking to apply for jobs out in California, but a resident on the other side of the country. As residents we get plenty of recruitment job advertisements but I’ve been told by a few folks that advertised jobs are not worth it and are “being advertised for a reason.” I’ve been told pulling connections is the way to get an “in” into where you want to go. How true is this? I have zero connections to California, and don’t even know which hospitals or clinics to reach out to. Should PGY-4s essentially ignore advertised jobs?

No particular advice, but even if you have 0 personal connections to California, do you know any alumni (or can your PD give you contact info for alumni) that are in the geographic areas that you are interested in? Advertised jobs are not necessarily bad although they often are, and the only real way is to try to talk to a psychiatrist that actually works there. Heck I've even gotten private messages on LinkedIn and the Facebook Psychiatry group (I'm public with my info there) from people who were interested in a job in/around where I work and ended up making a phone call with them to give some info, so maybe "cold messaging" someone might be useful.

 

[randomdoc1]

No particular advice, but even if you have 0 personal connections to California, do you know any alumni (or can your PD give you contact info for alumni) that are in the geographic areas that you are interested in? Advertised jobs are not necessarily bad although they often are, and the only real way is to try to talk to a psychiatrist that actually works there. Heck I've even gotten private messages on LinkedIn and the Facebook Psychiatry group (I'm public with my info there) from people who were interested in a job in/around where I work and ended up making a phone call with them to give some info, so maybe "cold messaging" someone might be useful.

you can never go wrong with networking! network network network. be a familiar face. going through resumes is like going through dating app profiles. they look the same (except for the really bad, really incredible/hot, and really eccentric ones but most fall in the middle of the bell curve). But if you stick out somehow, it's usually not a bad thing. practice what we preach. embrace the awkward. show you're not of afraid of doing your own exposure therapy. show you think outside the box! that action in and of itself demonstrates motivation, innovation, creativity, and being a provider of action. I love seeing candidates who initiate. anyone can mass send resumes but if you are reaching out and showing sincerity, that you read about the place and have a specific interest, that is another level of interaction.

As the saying goes, show you are not afraid to be a newbie or to suck at something new (also demonstrates emotional resilience and these mature defenses also rub off on patients -- such providers tend to be naturally good at what they do). We all gotta start somewhere. We may be senior in our medical training. But we are now n00bs in attending life. And that's ok! I was there once too and the faster I was humble and ready to up my game, the faster I advanced.

 

[tr]

Kaiser is pretty much always hiring right? Could start there and keep an eye peeled for better opportunities once settled.

 

[comp1]

Oh yeah, forgot Kaiser. I can't personally handle that sort of flow/workload, but they certainly are always hiring pretty much everywhere. Unfortunately I can confirm they have no inpatient jobs near Sacramento. In fact, I think they are looking to cut inpatient jobs there (they rent out beds at Sierra Vista covered by their own salaried MDs to get people out faster), but they do have outpatient. The Permanente Medical Group of Northern California

 

[Merovinge]

I think it's okay to have a less than perfect job coming out of training in a place you have no connections to. I took a job at a UHS hospital coming out of fellowship and I knew going in that it would be a short-term setup. I learned a lot, helped some patients out, and don't regret it. I also learned what I don't want in an attending job. You are going on what is essentially your first or second date, maybe there's a chance it works out, but I would plan for it not to. Make sure there is no non-compete, do good work for your patients, and do some networking and you will be able to find the better jobs once you make connections and have a reputation.

 

[randomdoc1]

I think it's okay to have a less than perfect job coming out of training in a place you have no connections to. I took a job at a UHS hospital coming out of fellowship and I knew going in that it would be a short-term setup. I learned a lot, helped some patients out, and don't regret it. I also learned what I don't want in an attending job. You are going on what is essentially your first or second date, maybe there's a chance it works out, but I would plan for it not to. Make sure there is no non-compete, do good work for your patients, and do some networking and you will be able to find the better jobs once you make connections and have a reputation.

I thought non competes are now deemed not enforceable anyways per the FTC? Anyways, I'm admittedly not the most up to date on this. But even if it was enforceable, I think the employer has to file a lawsuit anyways and the employer's gotta decide if it is worth their time or just move on. What I've learned being on both ends of the table is carefully walking through these relationships (whether you are an employee or an employer). It's like chess. I hate chess. I hate politics. But we will never get away from it. I try as feasible to leave a positive impression wherever I am while trying to preserve by own dignity and self respect. Relationships outlast roles, they can be really handy. The Godfather gives awesome advice ; ).

 

[comp1]

I'm guessing the FTC isn't going to help stop any company from enforcing a non-compete under the current administration. Fortunately, the OP is headed out to CA where non-competes have been banned by the state for everybody for decades, a big part of what made and continues to make Silicon Valley possible.

 

[randomdoc1]

I'm guessing the FTC isn't going to help stop any company from enforcing a non-compete under the current administration. Fortunately, the OP is headed out to CA where non-competes have been banned by the state for everybody for decades, a big part of what made and continues to make Silicon Valley possible.

probably. end of the day, boils down to what actually happens and if anyone tries to sue. back to what merovinge was getting at, yes, solid advice to make sure getting out would not be too much trouble. that's the biggie. I'm no attorney, but there is also another concept known as a no solicitation. Slightly different from non-compete. Don't know how enforceable it is. But with the no solicitation clauses, there is no radius. More that the provider agrees to try not to convince patients to follow them. How provable is it? No idea. End of the day it is one person's word against another. End of the day if a patient decides to look for the provider and follow them wherever they go, that is their right and no harm is done. Although it is good to be familiar with legalities, it's definitely only one aspect of the situation. The bigger lesson is trying to preserve bridges, try our best to not burn them, and how do we all peacefully agree to disagree without getting into each other's way. Ok, I'm digressing a bit. I guess what I'm trying to say is, career development, advancement, finding and making opportunities....there's so much to it. Connections is a biggie.

 

[comp1]

California generally doesn't allow non-solicitation clauses either! Seriously, you all are missing out with these bizarre trade restrictions. Patients can and should get care from the providers they want. The exceptions in CA would relate to trade secrets, not medical practice stuff.

 

[randomdoc1]

California generally doesn't allow non-solicitation clauses either! Seriously, you all are missing out with these bizarre trade restrictions. Patients can and should get care from the providers they want. The exceptions in CA would relate to trade secrets, not medical practice stuff.

there's definitely a validity to the different sides of the argument. I think since most of us are not on the employer end, many don't get first hand experience on why the trade restrictions exist. Most of the time, the discussion is not necessary, partings go fine (as they should!). But in some cases, there is a slippery slope. There have been situations where in my practice, a provider was starting their solo self pay practice. This was while they were still working for me and I was very flexible by most employer standards. One provider advertised themselves as accepting new patients under my company and made a misleading website. So when patients were trying to establish, they thought they were getting the brand and experience of RandomDoc's Clinic when this whole time they were being lured into a solo practice. I took screenshots of their marketing and needless to say, it was a super awkward conversation. It's an incident of someone trying to capitalize on the practice's free marketing and brand.

There was another incident couple years back, where a provider was leaving the practice and some patients specifically expressed wanting to stay in the practice. But they were told my practice cannot accommodate it (a lie) but conveniently said they could continue care with them where they were going. So those are incidences of active solicitation and inviting liability without the owner's knowledge.

Different story if a patient says "I want ___." I agree with the stance of, yes, consider it done. But the above situations happen more often than we realize. I was shocked myself at all the hub ub in HR.

In case it's not obvious, not trying to start a debate. I agree with the things you say. Just wanted to provide additional info! <3. But also hoping it delivers insights on why the other end of the table may seem sensitive about these matters. Even innocent intentions can be mis-interpreted by an employer. I try not to jump to conclusions when I encounter uncomfortable circumstances and try to seek clarification (with facts) before opening up tough discussions. But there is a backdrop and history of where it comes from. All the the more reason to keep communication consistent, clear, specific, professional and relationships going strong as far as both sides. It's an interesting position. I'm still a practicing physician but I also work on the HR end now as someone who started a place from scratch.

 

[AD04]

there's definitely a validity to the different sides of the argument. I think since most of us are not on the employer end, many don't get first hand experience on why the trade restrictions exist. Most of the time, the discussion is not necessary, partings go fine (as they should!). But in some cases, there is a slippery slope. There have been situations where in my practice, a provider was starting their solo self pay practice. This was while they were still working for me and I was very flexible by most employer standards. One provider advertised themselves as accepting new patients under my company and made a misleading website. So when patients were trying to establish, they thought they were getting the brand and experience of RandomDoc's Clinic when this whole time they were being lured into a solo practice. I took screenshots of their marketing and needless to say, it was a super awkward conversation. It's an incident of someone trying to capitalize on the practice's free marketing and brand.

There was another incident couple years back, where a provider was leaving the practice and some patients specifically expressed wanting to stay in the practice. But they were told my practice cannot accommodate it (a lie) but conveniently said they could continue care with them where they were going. So those are incidences of active solicitation and inviting liability without the owner's knowledge.

Different story if a patient says "I want ___." I agree with the stance of, yes, consider it done. But the above situations happen more often than we realize. I was shocked myself at all the hub ub in HR.

In case it's not obvious, not trying to start a debate. I agree with the things you say. Just wanted to provide additional info! <3. But also hoping it delivers insights on why the other end of the table may seem sensitive about these matters. Even innocent intentions can be mis-interpreted by an employer. I try not to jump to conclusions when I encounter uncomfortable circumstances and try to seek clarification (with facts) before opening up tough discussions. But there is a backdrop and history of where it comes from. All the the more reason to keep communication consistent, clear, specific, professional and relationships going strong as far as both sides. It's an interesting position. I'm still a practicing physician but I also work on the HR end now as someone who started a place from scratch.

A lot of times there seems to be a subtle conflict between laborers and capitalists. It’s easy to demonize the business owners and landlords because they’re “rich”. I personally cannot do what you do because it is a lot of responsibility. People’s livelihood will depend on me if I become a practice owner and I value my freedom too much.

Thank you for what you do to help provide jobs for the community and opportunities for other psychiatrists to make a living.

Recently, I told my landlady that I appreciate her a lot.

Those without much capital are not any more moral or trustworthy. I would argue that it would be the other way around if someone wants to be a long-term business owner in area with a lot of competition. Successful iterative games need honesty for further cooperation and mutual benefit.

 

[randomdoc1]

A lot of times there seems to be a subtle conflict between laborers and capitalists. It’s easy to demonize the business owners and landlords because they’re “rich”. I personally cannot do what you do because it is a lot of responsibility. People’s livelihood will depend on me if I become a practice owner and I value my freedom too much.

Thank you for what you do to help provide jobs for the community and opportunities for other psychiatrists to make a living.

Recently, I told my landlady that I appreciate her a lot.

Those without much capital are not any more moral or trustworthy. I would argue that it would be the other way around if someone wants to be a long-term business owner in area with a lot of competition. Successful iterative games need honesty for further cooperation and mutual benefit.

Thank you so much. This means a ton to me. My heart and soul is in the practice and it's really another one of my children. There was a lot of unpaid work put into it and much ongoing responsibility to keep the traffic and referral stream up. No one is paying you a stipend to do it. You are correct, I'm end of the day just trying to create a sanctuary for myself and others who have a similar philosophy of wanting a good work life balance. And you are right, people over estimate how much business owners have and under estimate dramatically the work that goes behind it. Just trying to create a warm community here of the right folks <3!

 

[Merovinge]

probably. end of the day, boils down to what actually happens and if anyone tries to sue. back to what merovinge was getting at, yes, solid advice to make sure getting out would not be too much trouble. that's the biggie. I'm no attorney, but there is also another concept known as a no solicitation. Slightly different from non-compete. Don't know how enforceable it is. But with the no solicitation clauses, there is no radius. More that the provider agrees to try not to convince patients to follow them. How provable is it? No idea. End of the day it is one person's word against another. End of the day if a patient decides to look for the provider and follow them wherever they go, that is their right and no harm is done. Although it is good to be familiar with legalities, it's definitely only one aspect of the situation. The bigger lesson is trying to preserve bridges, try our best to not burn them, and how do we all peacefully agree to disagree without getting into each other's way. Ok, I'm digressing a bit. I guess what I'm trying to say is, career development, advancement, finding and making opportunities....there's so much to it. Connections is a biggie.

These things are much bigger deals in my area than you are eluding to. I know of several (>3) significant/serious lawsuits related to non-compete breaches (or alleged breaches as the case may be). It's a huge suck for the doctor's dealing with them, I know one personally very well and know others professionally. You do not want to be fighting a PE company or large hospital chain lawyer team by yourself. The best cure is an ounce of prevention.

 

[randomdoc1]

These things are much bigger deals in my area than you are eluding to. I know of several (>3) significant/serious lawsuits related to non-compete breaches (or alleged breaches as the case may be). It's a huge suck for the doctor's dealing with them, I know one personally very well and know others professionally. You do not want to be fighting a PE company or large hospital chain lawyer team by yourself. The best cure is an ounce of prevention.

I completely agree--interpersonal relations. Don't do anything stupid! lol. In a unique position here as I understand both sides of the argument. I love AD04 saying the very grounded words that it is easy to demonize those with more capital. I'm nowhere near a hospital system. Some are familiar with my older posts but I came from a background of poverty and got to this standing with years of consistent grueling work. But it's extremely hurtful to me when I invite providers in (basically this is another home of mine), offer them double their salary at a fraction of the work they had at their last gig, only for some to try to demonize me. The greed and entitlement can be endless and some providers reach a point where they never get satisfied and demand completely unrealistic requests of the practice. Pay grades that would make the practice bankrupt and when you show the math that you are paying the most you can, it gets met with resent and them bringing a toxic attitude into the work day. I think some individuals demonize the employer to rationalize their soliciting patients from the practice they work at and/or rationalize their entitlement when it is actually an internal issue. It's just easier to blame something else. The amount of money one has does not make a person more or less moral. I've seen very affluent people be outright emotionally abusive to physicians but I've also seen it come from the impoverished. Primitive defenses is an equal opportunity entity! lol.

Definitely where we all agree on here is that we all try our best to act in good faith. Also, keep a good written thread. That's a saving grace. Employers can definitely exploit laborers and yes, the law tends to fall in the employer's favor. But employees are also capable of doing not the greatest things and the power discrepancy is definitely not an invitation to behave in certain ways nor does it make it ok. Very philosophical discussion!

There have been moments where I considered selling my practice, investing the money and just retiring early. Because I do get a share of entitled people that just don't appreciate what the practice tries to offer. It's emotionally draining. It's ironic that this is the biggest threat to the practice. It's the greed of others. It's like...why bother? But right now I have a happy medium. Be careful about growing too fast. Keep a comfortable group of the right people around you. Another reason I'm keeping this place going is I am emotionally invested in it but also in case my kids want to work here. It offers a comfortable job in case they develop an interest in the field. One or both of them seem to have a bit of a entrepreneurial mind, so they may do well taking over. Both my parents were self employed too and we all love the freedom, life balance and earning potential.

 

[comp1]

I know this is well outside the OP's topic now (particularly since all this trade restriction stuff is rightfully banned in CA), but something that occurred to me is why do practices care so much about "ownership" of patients? In that I mean...psychiatric panels shouldn't really be conceptualized as long term sources of income. The VAST majority of patients should be stepped down back to a primary care provider relatively quickly. Shouldn't most outpatient psychiatrist income derive from new intakes? The patients who need to see a psychiatrist for the long term typically have a primary psychotic disorder with Medicaid and probably aren't an income line that needs to argued over. Are these all pleasantly interesting people coming for supportive psychotherapy for decades? Patients with borderline PD where you're still holding on to hope that the 11th or 13th trial of a mood stabilizer or antipsychotic will be the one that finally removes their childhood trauma?

 

[randomdoc1]

I know this is well outside the OP's topic now, but something that occurred to me is why do practices care so much about "ownership" of patients? In that I mean...patients shouldn't really be conceptualized as long term sources of income. The VAST majority of patients should be stepped down back to a primary care provider relatively quickly. Shouldn't most outpatient psychiatrist income derive from new intakes? The patients who need to see a psychiatrist for the long term typically have a primary psychotic disorder with Medicaid and probably aren't an income line that needs to argued over. Are these all pleasantly interesting people coming for supportive psychotherapy for decades? Patients with borderline PD where you're still holding on to hope that the 11th or 13th trial of a mood stabilizer or antipsychotic will be the one that finally removes their childhood trauma?

As a friendly discussion, we can probably argue this of practice owners and employees. Like it or not, people do see patients as "clients". Physicians at my office get upset when a patient switches from them to another physician in the practice, especially if it was a "luxury" patient with good commercial insurance and easy pharmacotherapy. Sometimes even little spats start within the office of if a physician is suspecting another within the practice of "poaching" patients. But the way I see it, patient gets to choose. If they have the option, it is their right. Everything that generates revenue or a source of income is a business. Like it or not. Nothing in this world is immune from economics and we all understandably want income security and do not want a day full of drug seeking and non paying visits. It can literally make the difference of a luxury lifestyle to going bankrupt (with SA) as a working physician. Psychologically speaking, it boils down to how people behave about money. I told a resident, if we thought people's behavior about drugs of abuse was bad, money brings out even worse. Just think about divorces! As I progress in life, I now see why spouses kill each other LOL.

This in a way does loop back to the OP's topic. Maintaining connections and finding more opportunities, a big driver is about money. It's of course also about company culture and finding opportunities to do the type of work that you like. But let's face it, compensation is still a major deciding factor. I don't have the data to refer to but swear I read that there is good data to indicate those who strong interpersonal skills tend to be able to unlock the most earning potential and have more offers sent their way. No surprise. And this applies for the medical field as well.

As for my personal stance, I'm less bothered by patients following a provider elsewhere. I'm able to generate a new panel easily, but it would call for more unpaid work on my end. I think it is more to do with how people treat the practice. For example, if a provider is working at my practice and marketing themselves as taking new patients at my practice but luring them into a solo practice...that is a way of using my brand, SEO and work I put into this but not paying me for my work that helped you get patients. They are capitalizing off of someone else's work (kind of like a copyright?). Kind of like intellectual property? Now if they were presenting themselves as their own practice and the patient was browsing websites and chose their practice over mine, we're cool. But don't try to use my brand to attract patients to you (false advertising) when they are not even becoming patients of the practice. Referring back to the provider that did this, I asked her to remove all mention of my practice on her marketing. She must make her own brand and market as her own entity. She agreed to do that. It was a peaceful resolution. The outcome? Her traffic dwindled. Last I heard she can't even pay the rent for her office space. So some of it can be a more involved question. The brand was indeed worth $$. But...it's my brand : P.

 

[comp1]

Well...I appreciate the honesty... This is not good for medicine as a whole, however.

 

[randomdoc1]

Well...I appreciate the honesty... This is not good for medicine as a whole, however.

Wish I had a bright solution. I'm just not that smart : /. There is a way to practice good medicine still. Which I try my best to do. But we can only control ourselves and how we practice.

 

[FatherPsychiatry]

Like it or not, people do see patients as "clients". Physicians at my office get upset when a patient switches from them to another physician in the practice, especially if it was a "luxury" patient with good commercial insurance and easy pharmacotherapy. Sometimes even little spats start within the office of if a physician is suspecting another within the practice of "poaching" patients. But the way I see it, patient gets to choose. If they have the option, it is their right. Everything that generates revenue or a source of income is a business. Like it or not. Nothing in this world is immune from economics and we all understandably want income security and do not want a day full of drug seeking and non paying visits.

Like comp1, very much appreciate your perspective, sharing your experience, and upfront honesty with this post.

 

[clausewitz2]

Are these all pleasantly interesting people coming for supportive psychotherapy for decades? Patients with borderline PD where you're still holding on to hope that the 11th or 13th trial of a mood stabilizer or antipsychotic will be the one that finally removes their childhood trauma?

If this is your impression of the typical outpatient psychiatry patient I'm not shocked that you hate outpatient.

EDIT: So for example here is my rundown for today:

panic attacks and suicide OCD
existential and suicide OCD transitioning to OCD-dose clomipramine
harm OCD about murdering his parents
very somatic and anxious person in allied health profession
depressed enough to drop out of college now working full time on nortriptyline
GAD and ADHD with surprisingly brittle hypothyroidism
PTSD and panic d/o with agoraphobia
irregular sleep-wake rhythm d/o and NPD
OCD and severe cannabis use d/o
ADHD and GAD
bipolar I with psychotic features on lithium
harm OCD and narcolepsy

all but one of those patients has never experienced psychosis and the one who has does not have a primary psychotic disorder. I would argue that all of these patients probably ought to be seen by a psychiatrist rather than primary care and at the very least would all need to see a psychiatrist if significant adjustments needed to be made to any of their medications. Of course, you may disagree, but I hope to convey at least that you can be a) a legitimate psychiatric outpatient and b) not have SPMI or BPD.

 

[randomdoc1]

Well...I appreciate the honesty... This is not good for medicine as a whole, however.

This gave me an interesting thought. It can go either way. Yes, a provider can make bank selling fake medicine. Profit can incentivize all the wrong things. However, good medicine also sells quite well and there is a following of patients who do not like salesy providers. They want evidence based providers who work based off reliable data. That's the population I like working with. Salary models come with their own pros and cons. It can also incentivize under performance by a provider since they get paid the same anyways and this can even incentivize very low patient traffic. I've seen a share of colleagues during my days working at the VA. And there's definitely some providers who don't bother to establish rapport and only care to get through the visit and hit the refill button on the SSRI despite a severe MDE. If the patient does not return, great. They're on a salary anyways and are paid the same whether they see 12 patients or 0 patients that day. Moral hazard. Of course, I also know the VA monitors productivity and if anyone hits extremes, it does seem to get addressed, at least in my local VA. Ultimately, each provider needs to decide how they want to practice medicine. I remember writing a project paper in undergrad about for profit hospitals versus not for profit hospitals. If there is a difference in patient outcome and quality of care. If remembering that data correctly, it seemed to be quite mixed and not a straightforward answer. I have to toot my own horn...but I was the top performer in the healthcare econ lecture! Little did I realize how relevant that would be in the career path.

I lean a little more towards production and profit driven models. But it's based on my own life experience. My mother had her ethnic cuisine restaurant. To stay afloat, we need to serve good food (which starts with best ingredients, good cooking--short cuts never work), have good ambience, good service. If the product sucked, there goes your traffic and business goes belly up. Just like how fast food sells but there's also upscale places that are hopping. What population do we want to work with? We took our family business seriously and cared about it. Loved it. And that's how I treat my office. The funny thing? Many of my faithful patients are long time customers of her restaurant (so these patients have even been in my life since my childhood)! They joke and say they are lifelong fans of the Randomdoc lineage brand LOL. Although different clinic owners treat their practice differently and some do treat it as a cash cow with no regard for ethics. Maybe it boils down to the person?

 

[comp1]

So depending on where each of the symptoms described above are in terms of severity, I would argue they should stay with a psychiatrist. However, even with those complex patients, there still should be a long term plan to step them down eventually. Those patients are actually excellent examples because if they are indeed so complex and acute that they still need monthly follow-up with a psychiatrist, they definitely should be able follow their current psychiatrist where ever they go.

 

[clausewitz2]

So depending on where each of the symptoms described above are in terms of severity, I would argue they should stay with a psychiatrist. However, even with those complex patients, there still should be a long term plan to step them down eventually. Those patients are actually excellent examples because if they are indeed so complex and acute that they still need monthly follow-up with a psychiatrist, they definitely should be able follow their current psychiatrist where ever they go.

This would make us quite different from a lot of other medical specialties, who absolutely follow patients for many years regardless of stability. I'm curious, why do you feel we should be held to a different standard?

 

[randomdoc1]

My understanding is that in cases like borderline personality, good ongoing psychiatric care and corrective experiences are actually potentially very efficacious. Especially if access to other modalities of therapy is limited. We may be serving a bigger role than we realize. Most PCPs would not be well equipped for the ongoing care. It is possible that some will graduate to not needing psych follow up anymore. But some still benefit. And with good mental health treatment, it can optimize their outcomes and keep expenses and complications to more of a minimum.

 

[calvnandhobbs68]

This would make us quite different from a lot of other medical specialties, who absolutely follow patients for many years regardless of stability. I'm curious, why do you feel we should be held to a different standard?

Right, for example it used to be (before the adult congenital heart disease fellowship) and still is some places that kids with congenital heart diseases would keep seeing their pediatric cardiologist as adults (there would be like 40 year olds in the "pediatric cardiology" clinic) because even the adult CARDIOLOGISTS weren't comfortable seeing congenital heart disease.

Like yeah I think it's a bit of a big lift asking a PCP to try to manage someone's Bipolar 1 on lithium along with their HTN and DM2 or whatever or be able to figure out in a 10-15 minute followup if someone with self harm OCD is actually suicidal or just having an exacerbation of their underlying self harm obsessions.

So depending on where each of the symptoms described above are in terms of severity, I would argue they should stay with a psychiatrist. However, even with those complex patients, there still should be a long term plan to step them down eventually. Those patients are actually excellent examples because if they are indeed so complex and acute that they still need monthly follow-up with a psychiatrist, they definitely should be able follow their current psychiatrist where ever they go.

I do think psychiatry tends to follow people more closely/regularly than other specialists. But how exactly would they "follow their current psychiatrist wherever they go" if they move out of state or something?

 

[comp1]

It might make us a bit different, but the goal of pretty much every specialty should be to return a patient to their PCP after some sort of defined phase of treatment. I get there are chronic CHF or COPD patients where they aren't always successful in this goal, but even something like heme-onc...the goal should be returning to the PCP. Psychiatry just happens to be more upfront with the recovery orientation. I'm not saying every patient makes this easy. In terms of following their own psychiatrist, I assume that if the psychiatrist was moving out of state, they would not be getting into an argument with the clinic owner regarding poaching. This was in regards to the trade restrictions described above.

 

[Stagg737]

It might make us a bit different, but the goal of pretty much every specialty should be to return a patient to their PCP after some sort of defined phase of treatment. I get there are chronic CHF or COPD patients where they aren't always successful in this goal, but even something like heme-onc...the goal should be returning to the PCP. Psychiatry just happens to be more upfront with the recovery orientation. I'm not saying every patient makes this easy. In terms of following their own psychiatrist, I assume that if the psychiatrist was moving out of state, they would not be getting into an argument with the clinic owner regarding poaching. This was in regards to the trade restrictions described above.

I don't really agree that the goal for everyone should be to return to the PCP. This completely clashes with the reason for having specialists for chronic diseases. For example, a patient with something like Parkinson's or some other chronic (not necessarily progressive, but possibly) disease should be referred back to a non-specialist? I'll be honest, if it was my family I'd be pretty pissed if a specialist said, "well, they're good enough, back to the PCP". This may be fine for some psych patients where their condition can resolve (MDE) or go into long periods of stability (mild, well-controlled bipolar), but many psych conditions are chronic with fairly frequent relapses.

I've seen more than a few patients in my outpt consult clinic that I stabilized and referred back to their PCP who were referred back to me a year later when their condition recurred. I've gotten to the point that for some patients (depending on location and availability of services) I just tell the PCPs the patients aren't appropriate for my clinic as they'll need ongoing/long-term care. A schizophrenic patient whose baseline is barely good enough to stay out of inpatient psych hospitals are not appropriate patients to refer back to PCPs. If we can refer a patient back because they're doing really well and are unlikely to have a recurrence any time soon, then I'd agree that is the correct move. But I think you're either underestimating the number of chronically ill patients or the capabilities/skills of PCPs if you think most psych patients should or are even able to be referred back to PCPs.

 

[docloufan]

I think medicine has, obviously, become hyperspecialized. Whether that's good or bad? Idk. Probably not. But it depends on many, many factors.

Look...my wife's surgeon (recently) was great/fantastic, but after the reasonably designated recovery period, it was crystal clear that she didn't want that follow-up on her schedule unless it was outside someone else's ability.

If we truly believe in the recovery model of MH treatment treatment, why are so may people hanging around what is essentially psychopharmacologists and psychopharm appts? If you are doing actual niche, long-term psychotherapy with specific, measurable, and achievable goals, maybe it's a different story... but that probably not what is happening here.

Look...Hollywood can do the whole "therapy" for the past 10 years has helped me grow, "recover", see my flaws, make me a more focused/driven, etc...but that not really healthcare that most clinical psychiatrists should be worrying about, right?

Everyone should be focused on fostering how the person in front of me will NOT need my/your services any longer. Kinda like most other medicine specialties?

Is medicine a business? Doesn't mean you should think of every patient passing thru like revenue/a dollar sign. No. We cant have that.

 

[clausewitz2]

I think medicine has, obviously, become hyperspecialized. Whether that's good or bad? Idk. Probably not. But it depends on many, many factors.

Look...my wife's surgeon (recently) was great/fantastic, but after the reasonably designated recovery period, it was crystal clear that she didn't want that follow-up on her schedule unless it was outside someone else's ability.

I guarantee that a lot of that is because the payment is structured as a global fee for the surgery and all associated care, so every single post-op appointment was taking up space on that surgeon's schedule and generating no additional revenue.

If we truly believe in the recovery model of MH treatment treatment, why are so may people hanging around what is essentially psychopharmacologists and psychopharm appts? If you are doing actual niche, long-term psychotherapy with specific, measurable, and achievable goals, maybe it's a different story... but that probably not what is happening here.

Recovery is about regaining a life and functional status that the patient themselves recognizes as a life worth living, not about being "cured".

Everyone should be focused on fostering how the person in front of me will NOT need my/your services any longer. Kinda like most other medicine specialties?

See @Stagg737 's excellent point about chronic illnesses above and how our specialist colleagues treat them. It's important to make the distinction between "I'm discharging you because you don't have any problems I can help you with" and "I'm discharging you because of a vague sense that since you're not currently in the hospital you're fine."

You IP folks - how is it that you think that a lot of the people you would really prefer didn't keep coming back to your units manage to stay in the community? Not going to claim it's true of all of them, but for a good chunk, that is because they have consistent, long-term outpatient care.

 

[Merovinge]

I think medicine has, obviously, become hyperspecialized. Whether that's good or bad? Idk. Probably not. But it depends on many, many factors.

Look...my wife's surgeon (recently) was great/fantastic, but after the reasonably designated recovery period, it was crystal clear that she didn't want that follow-up on her schedule unless it was outside someone else's ability.

If we truly believe in the recovery model of MH treatment treatment, why are so may people hanging around what is essentially psychopharmacologists and psychopharm appts? If you are doing actual niche, long-term psychotherapy with specific, measurable, and achievable goals, maybe it's a different story... but that probably not what is happening here.

Look...Hollywood can do the whole "therapy" for the past 10 years has helped me grow, "recover", see my flaws, make me a more focused/driven, etc...but that not really healthcare that most clinical psychiatrists should be worrying about, right?

Everyone should be focused on fostering how the person in front of me will NOT need my/your services any longer. Kinda like most other medicine specialties?

Is medicine a business? Doesn't mean you should think of every patient passing thru like revenue/a dollar sign. No. We cant have that.

I am not sure what part of the country you practice in, but if you try to send back someone with schizophrenia that is "stabilized" to a PCP in any of the places I have practiced in, you would no longer having a working relationship with that PCP. It's patently absurd to me to not have a psychiatrist seeing these patient's regularly. When is the last time you have seen a PCP do an AIMS as just 1 of 1000 reasons why that's a terrible idea. There are dozens of other conditions in medicine that also fall into the category of clearly need to see a specialist for life. Many of my friends who are specialists see patients ad infinitum and are clearly doing the right thing for their patients.

 

[randomdoc1]

Is medicine a business? Doesn't mean you should think of every patient passing thru like revenue/a dollar sign. No. We cant have that.

I prefer for medicine to not be a business. But...we can't run away from the laws of economics. Until we get rid of all capitalism from society and maybe all forms of currency. Maybe then we can live in a utopia HA xD
But then that relies on all people behaving in good faith. And a lot of people just suck....so...I don't know where I'm going with this. I wish I had the solutions to the world's problems but I don't think any of us do. We're all trying the best we can.

I don't see patients as dollar signs but I do watch my budget, productivity, and fixed expenses (like rent, utilities, taxes, etc.). It sucks but is what it is.

 

[calvnandhobbs68]

Adding something else I forgot to put in before, I have quite a few especially young adults who don't HAVE a PCP. Sure, it's ideal for someone to have a PCP but there's plenty of people who don't have one and even if they establish care with one, aren't going to be eager to take over for psychiatry after only seeing this patient 1-2x. It's also kind of a dick move from my end to be like "hey you have to go find a PCP because you're too simple for me now"...I tell them everyone should have a PCP but I'm not going to kick them out because they don't have a primary care doctor.

I think child psych is actually relatively lucky in that I can be pretty sure almost 100% of my kids have pediatricians, but many pediatricians are starting to get out of their comfort zone as well once you're past like 1 SSRI or 1 stimulant.

 

[tr]

If this is your impression of the typical outpatient psychiatry patient I'm not shocked that you hate outpatient.

EDIT: So for example here is my rundown for today:

panic attacks and suicide OCD
existential and suicide OCD transitioning to OCD-dose clomipramine
harm OCD about murdering his parents
very somatic and anxious person in allied health profession
depressed enough to drop out of college now working full time on nortriptyline
GAD and ADHD with surprisingly brittle hypothyroidism
PTSD and panic d/o with agoraphobia
irregular sleep-wake rhythm d/o and NPD
OCD and severe cannabis use d/o
ADHD and GAD
bipolar I with psychotic features on lithium
harm OCD and narcolepsy

all but one of those patients has never experienced psychosis and the one who has does not have a primary psychotic disorder. I would argue that all of these patients probably ought to be seen by a psychiatrist rather than primary care and at the very least would all need to see a psychiatrist if significant adjustments needed to be made to any of their medications. Of course, you may disagree, but I hope to convey at least that you can be a) a legitimate psychiatric outpatient and b) not have SPMI or BPD.

I completely agree that these people as described should all have a dedicated psychiatrist whom they see regularly. It sounds like a very appropriate panel.

I think @comp1's point was that for every one of this type of patient, there are probably 10-20 uncomplicated anxiety or depression who are well managed on a standing SSRI and have a therapist they see regularly if needed, and who would be totally fine just getting their SSRI refilled by their PCP every six months.

 

[FlowRate]

It might make us a bit different, but the goal of pretty much every specialty should be to return a patient to their PCP after some sort of defined phase of treatment. I get there are chronic CHF or COPD patients where they aren't always successful in this goal, but even something like heme-onc...the goal should be returning to the PCP. Psychiatry just happens to be more upfront with the recovery orientation. I'm not saying every patient makes this easy. In terms of following their own psychiatrist, I assume that if the psychiatrist was moving out of state, they would not be getting into an argument with the clinic owner regarding poaching. This was in regards to the trade restrictions described above.

I have a more attenuated take on this. Patients with relatively common and primary-care appropriate presentations may get better up-front care (and more accurate diagnosis/helpful treatment planning) from a psychiatrist but the goal should either be to have an off-medications trial (first depressive episode) or to send to PCP (if recommending long-term treatment) once stable.

Patients on high doses, complex regimen, or medications PCP's are much less familiar with (antiepileptics, antipsychotics, TCA's, etc.) should continue long-term with the psychiatrist. Usually that also means the patient likely has some sort of relatively more severe disorder or that symptoms aren't 100% stable over time even on a good regimen. But also I see some of those patients (when they're stable) only once or twice a year, which is very different from some PP folks who don't allow anything less frequent than 2 or 3 months.

 

[mistafab]

I had a situation recently where I got someone out of severe TRD with nortriptyline. They were with me short term and needed to move back.

Pure stability, first time in years. Treatment-resistant depression.

Tried to send them to their psychiatrist, (who turned out they were an NP), who said "you'll need to switch meds or I will not follow you."

My example highlights that although we are capable and utilize these medicines daily. Even within the "mental health" field, you have a general anxiety from providers to manage what is working. We are just so bread and butter with it, it is hard to put us in the shoes of a PCP who gets someone back on sertraline + abilify and feels on high alert. This 'psych' provider was comfortable with dual antipsychotic (vraylar, + low dose seroquel) and lexapro, but uncomfortable with nortryptiline monotherapy.

 

[Stagg737]

I completely agree that these people as described should all have a dedicated psychiatrist whom they see regularly. It sounds like a very appropriate panel.

I think @comp1's point was that for every one of this type of patient, there are probably 10-20 uncomplicated anxiety or depression who are well managed on a standing SSRI and have a therapist they see regularly if needed, and who would be totally fine just getting their SSRI refilled by their PCP every six months.

Sure, and imo it's completely reasonable to try and return those patients to their PCPs (if they ever came to you in the first place). However, like I said before there are also plenty of patients who are returned to their PCP but end up back in our offices 6-12 months later because they're having symptoms again or because the PCP started a med or made a change that caused problems. One of my med school attendings had a bunch of patients he'd see every 3-6 months who were stable and just coming in for med checks/refills. His logic was "I got them stable, why would I send them back to the PCP who couldn't even handle basic depression/anxiety when I can keep them stable myself?" Being in an outpatient consult clinic and seeing this pattern frequently (even just doing 5-6 hours a week) that logic resonates with me more now.

The other side of this is that plenty of PCPs don't want to or even WON'T handle basic psych problems. I had to stop taking consults from one PCP because he refuses to even prescribe SSRIs. I told him he either needed to start doing it or fine a long-term MH practitioner to send his patients to and seems like he's decided to stick with the latter option. Not to mention the situation that Calvin mentioned where patients just don't have a PCP, which is unfortunately quite common in the most vulnerable populations.

 

[comp1]

I think it's totally appropriate for some patients to go back and forth between a PCP and a psychiatrist. Ideally you don't want that number to be high, but it shouldn't ever be zero or you're not sending enough patients back to their PCP. I view it kind of like an inpatient admission. You don't want bouncebacks, but you're not discharging enough people from the hospital or you're keeping them locked up too long if you NEVER have a bounceback. This balance is just on the opposite side of the severity spectrum. It's totally appropriate to have an agreement with any referring PCPs about what specifically they will and won't manage ahead of time. This is where it is honestly better to be in a system where PCP's aren't really given the choice, but it's all laid out ahead of time of what they will and won't be managing.

 

[hallowmann]

OP, I had no psychiatric connections in CA, yet still made it out. The more important thing for you to do is to start narrowing down the type of position you want, and they reaching out to and building connections in those arenas. In Nov of my 4th year, I reached out to mailing list for the type of psych I wanted to do, and I ended up getting directly in contact with med directors for positions I had already applied for months earlier online, but heard nothing from.

If this is your impression of the typical outpatient psychiatry patient I'm not shocked that you hate outpatient.

EDIT: So for example here is my rundown for today:

panic attacks and suicide OCD
existential and suicide OCD transitioning to OCD-dose clomipramine
harm OCD about murdering his parents
very somatic and anxious person in allied health profession
depressed enough to drop out of college now working full time on nortriptyline
GAD and ADHD with surprisingly brittle hypothyroidism
PTSD and panic d/o with agoraphobia
irregular sleep-wake rhythm d/o and NPD
OCD and severe cannabis use d/o
ADHD and GAD
bipolar I with psychotic features on lithium
harm OCD and narcolepsy

all but one of those patients has never experienced psychosis and the one who has does not have a primary psychotic disorder. I would argue that all of these patients probably ought to be seen by a psychiatrist rather than primary care and at the very least would all need to see a psychiatrist if significant adjustments needed to be made to any of their medications. Of course, you may disagree, but I hope to convey at least that you can be a) a legitimate psychiatric outpatient and b) not have SPMI or BPD.

Bro, I don't know what your definition of SPMI is, but those patients all sound like they have SPMI except maybe the ADHD/GAD patient, but this really depends on the level of functional impairment.

In any case, I really think you guys are talking past each other a bit and your main disagreement is a matter of where on the line you think patients fall. Your patients sound like patients that should see a psychiatrist, so its good they're seeing you.

As an aside, I personally would hate having your patient panel, but it sure sounds like you'd hate my patient panel full of BPD/PTSD, bipolar disorder, and primary psychotic disorders. To each their own.

This would make us quite different from a lot of other medical specialties, who absolutely follow patients for many years regardless of stability. I'm curious, why do you feel we should be held to a different standard?

As someone trained in FM as well, I'd actually say this is not different from other specialties. Most specialties aim to achieve stability then stretch out follow-ups to 1 yr or just send people back to their PCP on a stable med regimen. I think this is most clearly represented in resource poor areas, where access to other specialties also more clearly mirror access to psychiatry. This isn't a different standard.

 

[clausewitz2]

As someone trained in FM as well, I'd actually say this is not different from other specialties. Most specialties aim to achieve stability then stretch out follow-ups to 1 yr or just send people back to their PCP on a stable med regimen. I think this is most clearly represented in resource poor areas, where access to other specialties also more clearly mirror access to psychiatry. This isn't a different standard.

I can accept there are big regional differences here, especially between resource-poor areas and areas with large AMCs. I think of the number of patients I personally have who appear to be seeing a cardiologist for HTN on 1-2 anti-hypertensives with no major complications or nephrology three times per year for extremely stable Stage 1 CKD and have to conclude we work in areas with very different follow-up cultures.