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In his defense, I've seen some of your posts that say every other specialty is better.
race to the bottom job offer....
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In his defense, I've seen some of your posts that say every other specialty is better.
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Fooled me. I stand corrected, best of luck.
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It's the mindset that most of us would loathe to inhabit. That you or I would be miserable in. And of course, there is an overarching thesis that is implicit in a "race to the bottom" thread title. That is not manned up to explicitly, but instead promulgated surreptitiously in contrarian style.
In other words, if one wants to practice a respectable level of psychiatry one has to putz around in a slow outpatient clinic making a salary only a trophy husband of a physician with little to moderate debt level could accept. Further, that NP's and Rx-writing psychologists are better equipped for our line of work. This is what you're reacting to.
It's a thesis that negates what many, I would say most, of us are doing or plan on doing with this career.
I do not accept its premise or conclusions. Nor do I have the luxury or temperament to do so even if I wanted to.
I have come to enjoy your language on SDN, and apologize for my previous snarkiness about it
As a contrast to the race to the bottom (not a criticism/argument/whatever), I worked with an attending today who had what I would consider a awesome job - works in the psychiatric emergency room 3 shifts a week (Which satisfies the requirements for a full time post), which is intense, but as you have alluded to before, real honest work, and then spends the other two days pursuing hobbies and doing some research. They live very comfortably with two kids. I could imagine doing that and running a small private practice on the other days, which would be both satisfying and lucrative.
promulgated surreptitously in contrarian style.....lmao.....that is hilarious.
and you're imagining things again-I've never indicated I plan to 'putz' around or that my clinic will be slow. I could round mindlessly on a gazillion inpatients(or do inpatient period) and make decent dollars....just like anyone could. I could also shuffle outpatients through like cattle and make decent money...like a lot of people do(and then tell themselves they provide quality care). What I'm doing is different than that. That doesn't mean I am 'putzing' around or that it is slow. Or that I will help many patients myself. And heck I may not even be particularly good at it-since I'm constantly reminded in here any decent psychiatrist who wants to spend time with patients can simply open up a cash pay private practice and start counting money.
I have come to enjoy your language on SDN, and apologize for my previous snarkiness about it
As a contrast to the race to the bottom (not a criticism/argument/whatever), I worked with an attending today who had what I would consider a awesome job - works in the psychiatric emergency room 3 shifts a week (Which satisfies the requirements for a full time post), which is intense, but as you have alluded to before, real honest work,
and for people who want to do that, good for them. Personally I think of 'er psychiatry'(and I know and like many people who work in that capacity) in a similar way as I do most inpatient psychiatry. So it's not something I'm interested in doing.
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Well idk then. Do your thing. I'm not convinced you're sincere about anything. But what does that matter to either of us? 100,000 is not a job I can afford to take, so I guess I'm stuck grinding it out like the rest of the stiffs. But...I will say this...if pride in yourself and this work and a more passionate and engaged perspective on it was something that emanated from your online presence...I guess I missed it. Badly. Carry on.
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In his prime, Vistaril's threads produced such an angering countertransference that I think perhaps he does belong in psychiatry... as a subconscious patient.
oh heck I can't afford it either. I have loans that will only continue to grow. After thinking about it some more, I'm not going to do ibr. Just going to pay it back on 10 year plan. So I'm looking at 2400/month there before a single bill is paid. And my take home after taxes on 105k on 1099 work? Well the math doesn't look good....
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No offense, but it looks like you're actively seeking the lowest possible salary in existence for psychiatry. It doesn't take an actuary to notice the rather bizarre bind you're choosing to put yourself in.
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I used to have the stamina to do this type of work but not anymore. Residency was fun but real work can be mentally exhausting and unsatisfying. The time crunch you are describing is real and in my opinion a way to keep salaries artificially inflated. Yesterday I had 20 min to see a pt for the first time: 75 y/o with no PCP, tons of meds from urgent care, with symptoms of Lewy body dementia and a MOCA of 10 that nobody else picked up on, and family desperate for answers because they were told it was Bipolar disorder...f***.
There are small victories here and there but I would be lying if I said I didn't come home wiped out. I can't see myself doing this type of work 40 hours a week. Ideally I would have 7-8 45min sessions per day 5 days a week (but I am finding this to be difficult even in a cash model as therapy is not always indicated). Ironically as one of the harder working residents I took a part-time employment position and said to hell with it I'll take the pay cut. Maybe you should too Vistaril. The money may not buy you a beach house, but you may be happier just living day to day with basic necessities.
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Just to clarify in those 20 minutes I need to not only interview/examine the patient and talk to the family... I need to review records, write the note, enter the labs, write the prescriptions, fill the billing sheet, complete the appointment sheet, perform a level of care screening, med consent form, pcp communication form, and quickly touch base with the RN and case manager. Between patients I get bombarded with updates, labs, med refills, faxes, forms, random emergencies, doc-to-docs, grievances...its pretty insane.
I'm actively seeking working within a model I find useful/ethical/reasonable/humane. If it paid 200-250k a year I would gladly do it(and be very happy it did)
It's not like I said- how do I find the lowest paying job out there?
yep that's the thing....these people who say they do 3 followups in 1 hr and act like that is not a cattle call(just because it isn't 4, 5, or 6 an hour) aren't spending anywhere near 20 meaningful minutes with patients. A *ton* of stuff is involved within that which is not related to listening to the patient or assessing him/her in any meaningful way. Heck even down to things like going to get the patient.
In many systems a few of the things you mention above can be done by the office people(again depending on the system), but there is still a ton of stuff on both ends of the visit that cut into meaningful time. If one were to actually do a study on the amount of meaningful clinical time a psychiatrist who schedules 3 followups an hour spends with a pt on average, it would definitely be no more than 10 minutes I bet. And that's 3/hr.....4 or 5 an hour is obviously even more absurd.
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Then do a cash practice at $100/hr.
Im not sure that's a lot better than I am going to get now. I'm not even sure it would be more. It may be a little less with more hassle and work.
then consider that my total compensation package(salary of 105k + medmal with tail worth about 5 + disability and license fees worth 2-3)...that's 112-113k. Which on my current schedule comes out to about 68 dollars an hour. Which means that there is only 32 dollars an hour wiggle room for all the overhead, no shows, cancellations, collection misses, etc.....that's not a lot of wiggle room, even with a super lean operation. Even if I did somehow come out a little ahead(which would be very very hard to do), it would still be a big hassle.
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Fonzie, if its your PP and you're calling the shots, then why the heck didn't you allocate more time to this patient??
If I ever have a solo practice, then I will allocate 1 hr per pt. And if that means I only get to see 5 patients a day at, say, $300/hr, I'd be satisfied.
fonzie has another salaried/hourly job at a cmhc or agency type place. When you work at jobs like this, you most definitely don't call the shots. You're paid to move meat. If they pay you $110 an hour(or whatever), you can bet they are making more money than $110 an hour off you. Now consider what Medicaid/medicare reimburses, and consider their overhead...that's a good starting point to see how much meat they are going to expect you to move.
I don't wish you bad things for your private practice at $300/hr. But realize that for every 1 outpatient encounter with a psychiatrist in this country where the patient pays out 300 dollars, there are probably 1000 encounters where the patient doesn't(and that includes many other cash pay encounters). Hey that's not to say that you, Leo Aquarius, won't be the guy who is booking tons of patients at 300 cash pay/hr.
I hear a lot of talk about san Francisco and LA in these 300/hr discussions. Well everything I read says that Kaiser is coming to dominate the California market. What's more....Kaiser has hired and employs a *ton* of psychiatrists in their system in California. So my natural question is what are all these Kaiser psychiatrists doing? Certainly not seeing patients in network, because I've been told that the market in San fran and LA is all cash pay 3-500/hr.
Another important distinction is that our support staff in these types of jobs are FAR LESS than the support staff in high volume internal medicine group practices.
Those guys, because they can do far more volume, have support staff to do basically all that for them. It's all lined up perfectly for them.....like a well orchestrated assembly line. The difference is that our assembly line is a cluster****.
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You can believe that Kaiser is cornering the market, but the fact remains that private practice is healthy and thriving in California. You can believe whatever you like, I don't care especially since it's Vistaril talking, but I'm here in the thick of the California scene and see what's happening first hand. I'm not worried. New residency grads from my program and neighboring programs are going out and starting their own practices (but *some* people who don't even live in California say that Kaiser is cornering the market). Fly out here and see for yourself what the reality is. I'm not making anything up.
Some day soon I'll come back here and tell you what I'm charging per hour, and it will be the going rate in these parts.
I think what annoys everyone is that you talk like you know better, like what you think is fact and everyone else must be wrong. And so often you're the one who's wrong. Someday you'll realize the truth exists outside of yourself.
Some day soon I'll come back here and tell you what I'm charging per hour, and it will be the going rate in these parts.
I think what annoys everyone is that you talk like you know better, like what you think is fact and everyone else must be wrong. And so often you're the one who's wrong. Someday you'll realize the truth exists outside of yourself.
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you're misrepresenting(as usual) what I said. I never said cash pay private practice isn't feasible in California. It obviously is for some. And it's obviously feasible for many psychologists as well.
but it's a fact that the great majority of outpt psychiatric services in California are not provided under this model of care(3-400/hr cash pay). I don't need to be in California to know that anymore than I need to be on Mercury to know it is hotter there.
Of course even amongst the cash pay psychs who list cash pay fees of 350/hr, that doesn't necessarily mean they gross >500k a year. Heck many lawyers list rates of 200/hr and don't even gross 100k. And with a lot of these people a listed rate is much different than their effective rate. Sort of like income taxes.....
Now you may go out and become a great cash pay success. Good for you. for all I know you will make more money in mental health than dr phil. And kudos for you for not wanting to grind but rather spend time with your pts. But another thing to consider is what your pt population(and the pathology) is going to be like if you only see people who can pay you 350/hr out of pocket. Do you only want to see that population and that 'pathology'?
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We all have our cross to bear.
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It's the debt/income ratio that I'm looking at.
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This shows me that you haven't spent the time to run the numbers at all. A psychiatry practice with 30+% overhead?! Unless you are in NYC or California, your practice should be much leaner!
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You are definitely right for a standard psych practice. But a ridiculously low rate $100/hr cash practice can easily eat up that amount of overhead (given the slightly reduced hours that vistaril wants to work, and no shows, that overhead rate would amount to about 45 k)
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That still doesn't make it poverty. A $110k/year job with $200k debt burden is still many multiples better off than $20k/year with no debt.
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Oh god, this is a CONTRACTING gig? Sorry, the salary just took another hit.oh it's a 1099, so the 'effective salary' is actually a little less. They are just paying the license, malpal, dea, etc just out of their pockets. But the lack of other benefits would explain the 1099. So I can work my taxes a little better perhaps but Im going to be hit both ways on the fica
If you're happy with it, I'm glad, but I have a hunch you'll be seeing you can hang your own shingle with better pay and even more freedom very quickly. I'd be very careful about a non-compete since if those are the best jobs you're seeing, I have a hunch you're geographically constrained (or expect to be) and a non-compete can be something you'll regret. You've demonstrated pretty (ahem) strong opinions and strike me as someone who will prefer working for himself, so I'd think it through very carefully.
not to ruin all the dreams of making tons of money catering to wealthy patients, but if you're an img it's going to be even more difficult to command that sort of money in a cash pay practice.
30% overhead isn't unreasonable at all in thats scenario....even with no employees and a cheap office rental, I could easily imagine overhead in excess of 30 dollars per hour when you total everything up.
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Not necessarily. That's a self-fulfilling prophecy.
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I think CMS just recently increased psychotherapy add ons by 50% after the APA fought for higher reimbursement. At least now we are getting paid more than social workers for the actual time we spend providing therapy. Now they just need to get it right and raise it another 100%.
I guess the question to that would be: is there any evidence we as a group are better than lcsw/lpcs at providing therapy?
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It just depends on how you structure the business. In certain regions, rent is very cheap especially for small office space. Add in no-show fees and other appropriate fees (forms, records, etc). Create on-line scheduling or return VM to schedule yourself. No office staff. Google phone line attached to your cell. Free EMR or paper charting. Go to a home model auction and pick up discounted nice office furniture.
This structure could keep overhead well < 10% if you do it right.
There should be no shortage of patients at $100/hr. Insurance could reimburse the majority of the fee and I see my doc for 45 min follow-ups! Do some networking and the schedule will fill fast.
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I have to admit that I am envious of Nasrudin’s word smithing abilities. It makes me wonder what his notes read like.
“After serving the patient an involuntary hold, the patient suggested that I had an overly ambitious and unique resolution to my Oedipas complex.”
“After serving the patient an involuntary hold, the patient suggested that I had an overly ambitious and unique resolution to my Oedipas complex.”
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I think those overhead numbers are absurd. Even as a hypothetical, I think they are. Fonzie, what is your overhead running vs scheduling projections(including no shows, no pays, etc)
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You can argue all day long, but no private practice is the same. You can run it extremely lean (especially after start-up costs) or run it geared at productivity.
Using unused family property, I could have an entire house zoned as multi-use as an office. I could offer to pay taxes, upkeep, and bills for about $400-500/month. Add a couple hundred for Google ads, paper, pens, phone, etc. $100/45 min FU gets me $4800/week at 32 clinic hours. That's $19200/month. 11 months of work tops 200k. $800/month in overhead (generous in this scenario) is less than 10k/year. Malpractice in this region + licenses is less than 10k.
I'm still under 10% overhead with 32 clinical hours/week with a month of vacation. Basically your terms. If you had land and a guest house, it could be cheaper. Work more hours - cheaper still.
I could also have a huge office on Main St for 80% overhead. If you look at everything as "impossible", it will be.
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I think we bring a lot to the table when it comes to therapy for complicated medical/psychiatric and personality disorders. We have advanced training and exposure in all of these areas. Individual skillset, personality, willingness to examine transferential issues, and ability to connect with with patients are significant factors which makes your question even more difficult to research.
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Overhead started out at 100%. I just recently crossed the 50% mark. As I get busier the overhead will continue to shrink. At maximum capacity I am guessing less than 10%. It will take years for me to get there if I ever do.
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What is your rate per hour?
Obviously higher rates will be more difficult to fill a schedule. At $100/45 min, I think I could fill 32hrs/week with good networking and strategic marketing in 6 months.
$350/hr with a 50hr/week schedule would take much much longer with regional variation.
My one comparison at $350/hr took 7 months to fill 20 hr/week. It took significant non-clinical time to get there. She stopped there as she doesn't want to work more than 24 hrs/week including admin time.
well I don't have 'unused family property', so that's out.
Also 4800 for 32 clinical hours is 150/hr. I can't get cash pay patients at that rate. That's a big difference than the original 100/hr. 150/hr is close to the effective cash rate of what a very experienced mgh trained analyst here charges....no way I compete with that.
If it were as easy as you guys imply, everyone would be doing it(cash pay, long appt, outpt). The fact is most, the vast majority arent. Most are making a good bit more money than me true. But they are doing it in a practice modality that I don't find acceptable.
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True, but is generally easier to run a low Percentage overhead practice if revenue is higher. $5000 in licensure and malpractice fees is a much lower perecentage of a 500,000 revenue practice than a 150,000 revenue practice. Good point about running a lean practice.
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150/hr would be too low a charge for a standard psych practice (I have seen psychiatrists 4 years ago charge $125-150 for a 30 min appt). The same may not be possible in your area, and you got to do what you find acceptable to practice in your desired method of practicing.
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Don't worry Eeyore, you can make a living as a psychiatrist.
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Agreed. My cash rate is $120 for a 20 min follow-up.
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$250 per hour
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I respect your right to privacy regarding your location, but.... Unless by "here" you mean in your particular office building, I would be shocked to learn that there are particular regions large enough to support cash only practices in which the literally top folks charge $150/hr.
We consistently have this back-and-forth in which your view of psychiatry is completely at odds with almost everyone else's. It's either your viewpoint, or you live in a very odd pocket of the country where internists keep buying up multiple beach homes as the moguls that they are and the regions top psychiatrists make less than accupuncturists and massage therapists.
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eh I don't mind....at the moment I stay in Birmingham, Al. There are two dynamic oriented people in this city who many would consider the 'top' in terms of psychiatrists who provide therapy. I wouldn't put their names out there but they probably wouldn't be too hard to find if you cared to as I've already mentioned a little about their experience and pedigrees. Their listed fee is 200/hr, but their effective rate is closer to 150 after considering discounts for various reasons. I'd argue that somewhere like Birmingham is far more representative of the rest of the country than the upper east side of manhattan, the better areas of san francisco, or los angeles. Yes it's in the deep south, but it's population density is neither very high nor very low. It has some pockets of relative affluence(a couple suburbs of birmingham are fairly affluent). It's a metro area of maybe 800k(the metro area is actually listed at about 1 million but I think that's going to far out). It's not like this metro area is a small town of 4000 or something. It's pretty hard to make the case that this area is somehow less representative and 'very odd' compared to parts of manhattan and san fran for example.
As for my views being completely at odds...well I only know my life. But all the articles I read in various magazines on the state of mental health are similar to what I see(maining complaining how volume based med mgt is the standard). The job offers I explore from various parts of the country are similar to what I see. I never denied the existence of 300+/hr cash pay psychiatrists. I simply have stated that such a model is not nearly as common as the high volume med mgt insurance based psychiatrist. Now what I'm going to do(low volume, fairly low pay insurance based) is also not common, but I'd rather do that than the alternative that is reasonable and within reach for me(inpatient or high vol med mgt outpt)
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FYI salaries in Alabama
http://www1.salary.com/AL/Birmingham/psychiatrist-salary.html
Salary.com
Psychiatrist Salaries in Birmingham, AL
10th - 150k
25th - 168k
50th - 188k
75th - 209k
90th - 229k
Or
Occupational Employment and Wages, Bureau of Labor Statistics (United States Department of Labor)
http://www.bls.gov/oes/current/oes291066.htm
Annual mean wage of psychiatrist by state
Alabama: 199-232k
Which is the category of highest mean salaries for Psychiatrists in the United States and likely the world.
You're in the best of possible worlds.
Don't assign your low self esteem to every psychiatrist. You think you are interchangeable, yet phenomenal doctors make themselves irreplaceable. Your thinking will ensure limited professional growth and opportunity.
Many psychiatrists will be magnitudes better than lcsw's.
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have you paid attention at all in this thread, or are you just slow? I've never argued with those averages, or the idea that the salary I'm taking is low. I have stated that very very few psychiatrists anywhere practice under a model that I find reasonable. I'd rather practice in a way that provides at least an attempt at decent care than be assured of making above average salary.
