Satisfaction in Psychiatry

[Ellomate]

How is it possible that majority of the psychiatrist in SDN & Reddit are happy.

Like with selection bias, it's easy to find people who regret their field (IM, anesthesia, rads, peds, FM, etc).
But it's so hard to find psychiatrist who dislike their specialty - everyone seems to LOVE IT.
I think I found only ONE psychiatrist who truly regretted their decision...
So what's the deal?

Was psychiatry always a match made in heaven since medical school?
Did no one have a hint of hesitancy/reservation going into the field?
Are psychiatrist just more in-tune with their emotions and can find serenity/peace in whatever environment they are in?

Also divorce rate is the highest in medscape survey. Can anyone speak on regarding this matter?

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[FlowRate]

It would be an interesting topic to "study" in more detail.

Psychiatry has its stresses and specific jobs can be really taxing but, as far as doctor jobs go, it's a lifestyle specialty. Low call, low hours, patients aren't easily/frequently dying on you when you screw up, better pay than some harder specialties (primary care, peds.)

I think the introspection/emotional intelligence piece is part of it as well.

As for divorce rate, I think it's probably truth that psychiatrists as a population sample do trend more neurotic/odd and also might be more likely to be in a therapy that helps them clarify that their marriage is making them truly unhappy.

 

[nexus73]

I'd guess for someone to choose psychiatry they have to be pretty sure it's what they want to do. There's a lot of pressure against psychiatry in general (historically) because "you're not a real doctor anymore", so if you choose it you must be pretty confident it's what you want to do. Plus, once you get out of training the work life balance is pretty good. You can make a lot of money if you choose to be busy, but a lot of people only work 3-4 days a week and my guess is that flexibility leads to psychiatrists being pretty content. Theres a lot of practice options as well, whereas if you become a cardiologist you pretty much have the same job wherever you go. Psychiatrists can do outpatient (insurance or cash only), inpatient, community mental health, ACT team, addictions, jail/prison, state hospital, psychotherapy only, nursing homes, intensive outpatient, partial hospitalization, emergency psych. So if you get tired of your inpatient job, you could switch to clinic, or work at the jail, etc etc. Those options are very nice.

 

[deleted1100659]

How is it possible that majority of the psychiatrist in SDN & Reddit are happy.

Like with selection bias, it's easy to find people who regret their field (IM, anesthesia, rads, peds, FM, etc).
But it's so hard to find psychiatrist who dislike their specialty - everyone seems to LOVE IT.
I think I found only ONE psychiatrist who truly regretted their decision...
So what's the deal?

Was psychiatry always a match made in heaven since medical school?
Did no one have a hint of hesitancy/reservation going into the field?
Are psychiatrist just more in-tune with their emotions and can find serenity/peace in whatever environment they are in?

Also divorce rate is the highest in medscape survey. Can anyone speak on regarding this matter?

1. no, it was something I discovered I really liked, and was really the only field I could see myself doing long term, wasnt really for sure until end of third year

2. not really, difficult people are everywhere. These people still see other doctors

3. Im just amazing?

4. but I did get divorced, yes. Divorce rates are high no matter what you do. marriage just isnt easy, and takes a lot of work. sometimes people are just way too different, and people often want to overlook things and hope for the best. Thats a whole different ballgame in itself.

 

[comp1]

Psychiatrists are pretty darn happy in their profession, yes. We have by far the most direct control over our practice of anyone. I do think a lot (not all) of us chose it because it we hated everything else in medicine. It's more once when you've been practicing for a long time that you really appreciate it for it is as opposed to what it's not (ie the horrors of the other specialties). I think most people have a lot of hesitancy. There's a lot of societal pressure to do something else. Psychiatry doesn't have that same prestige with the parents that being a cardiologist does, although you might end up making the same amount (and working a lot less). Divorce seems...unrelated? I'm not sure. The common belief of mental health professionals working through their own issues in practice isn't entirely untrue.

 

[Mad Jack]

The studies on psychiatrist divorces is rather old and represented a very different time in the field. Often, psychiatry was a backup choice for IMGs trying to get into any field they could manage in the USA rather than a field they truly cared for. This isn't a field with a high degree of tolerability for those that do not enjoy it, and misery at work breeds misery at home. I think recent years have seen an increase in psychiatry residents choosing the field because it is what they want to do, not because it's their only option, and this has led to a more positive field in general. This is just speculation though, can't say whether it's accurate

 

[WisNeuro]

The studies on psychiatrist divorces is rather old and represented a very different time in the field. Often, psychiatry was a backup choice for IMGs trying to get into any field they could manage in the USA rather than a field they truly cared for. This isn't a field with a high degree of tolerability for those that do not enjoy it, and misery at work breeds misery at home. I think recent years have seen an increase in psychiatry residents choosing the field because it is what they want to do, not because it's their only option, and this has led to a more positive field in general. This is just speculation though, can't say whether it's accurate

Most of the "divorce stats" lore and what people cite is full of methodological errors. Not familiar with the medscape stuff, or how it was done, though.

The Divorce Rate Is Different Than You Think

Divorce tracking is flawed so the precice divorce rate is unclear. But studying marital trends and current statistics gives us a rough idea.

www.fatherly.com

 

[wolfvgang22]

I went to medical school expressly to become a psychiatrist. I worked as a mental health social worker before med school, and dropped out of psychology grad school because being a physician made more financial sense for me.

The things I am unhappy about have little to do with psychiatry, which I still love, and everything to do with ever increasing paperwork, bureaucracy, loss of physician autonomy, and our broken social and healthcare "system" that all medical doctors share. These factors are things that have impacted my mental health and marriage negatively, but my spouse and I work it out eventually. Just being any kind of doctor these days is what is toxic. Anecdotally I've seen a lot of surgeons divorce but hardly any of the psychiatrists I know.

 

[painballer27]

Low call, low hours, patients aren't easily/frequently dying on you when you screw up, better pay than some harder specialties (primary care, peds.)

Does it really pay better than primary care? For example, I'm aware of family medicine docs in smaller towns who see 30+ patients a day 4-4.5 days a week and make very good money (~500k). Is this doable in psych? I feel like it would be harder for a psychiatrist to see that much volume

 

[painballer27]

You can make a lot of money if you choose to be busy

How much?

 

[painballer27]

Psychiatry doesn't have that same prestige with the parents that being a cardiologist does, although you might end up making the same amount (and working a lot less)

Is this true? I know few cardiologists who make 5-800k. This is doable in psych with less work?

 

[erg923]

There are some people on here who either regret their choice and/or are relatively disenchanted. I don't think they post all that often? This is fine though, and too be expected in most any profession.

I am psychologist Ph.D, and maintain some clinical work, but mostly do other things related to mental health oversight, quality control, and business/market development. Some of the clinical psychiatry jobs I hear about on here sound cool (if I was a psychiatrist), but many sound like more of a clinical grind than my personality can handle/is cut-out for. Solo private-practice of any kind is also just too much patient contact and too much business-management for my particular taste. Only in the last few years have I (we) become really skilled at managing our own personal/home economics and building wealth, and I have little desire to manage the books elsewhere in my life.

 

[FlowRate]

Does it really pay better than primary care? For example, I'm aware of family medicine docs in smaller towns who see 30+ patients a day 4-4.5 days a week and make very good money (~500k). Is this doable in psych? I feel like it would be harder for a psychiatrist to see that much volume

Comparing outliers is not easy. Generally a basic employed psych job will pay more and be less work than a typical employed primary care job. Private practice numbers are going to vary wildly with all sorts of factors. It's not as easy/straightforward for us to make as much $$/hr as certain procedural specialties although typically those specialties, due to the nature of the work, don't have the luxury of choosing to work "park time."

There's a psychiatrist (and sellout) in my area who does a bunch of integrative/holistic/naturopathic stuff and charges roughly $700/hr and states on her website that she's full. But I wouldn't say that every psychiatrist could just "decide" to make that much money and also actually fill with (unfortunate) patients.

 

[UTsksk]

For me Psychiatry is meh. I got hit with reality that it’s just a job and not some divine calling. I care about my time and my family’s time. I keep thinking of adding sleep or palliative care to mix it up a little. I even briefly contemplated doing FM or IM, but I just have 1 more year of child psych and I’m burnt out from training.

Can’t guarantee I would go back and do psychiatry again but then again the grass isn’t always greener with other specialties.

 

[painballer27]

For me Psychiatry is meh. I got hit with reality that it’s just a job and not some divine calling. I care about my time and my family’s time. I keep thinking of adding sleep or palliative care to mix it up a little. I even briefly contemplated doing FM or IM, but I just have 1 more year of child psych and I’m burnt out from training.

Can’t guarantee I would go back and do psychiatry again but then again the grass isn’t always greener with other specialties.

Dang sorry to hear that. I mean I feel like a lot of physicians and people in general treat heir job like a job. But maybe when you start stacking paper you’ll enjoy it more

 

[erg923]

For me Psychiatry is meh. I got hit with reality that it’s just a job and not some divine calling. I care about my time and my family’s time. I keep thinking of adding sleep or palliative care to mix it up a little. I even briefly contemplated doing FM or IM, but I just have 1 more year of child psych and I’m burnt out from training.

Can’t guarantee I would go back and do psychiatry again but then again the grass isn’t always greener with other specialties.

Work is called "work" for a reason, right?

Hopefully one can get some degree of pleasure and mastery from "work" but I have always cringed at the term "calling" or any other labels given to doing and managing your "professional work"....in which making money is the key factor/ingredient within the definition of the word.

 

[nexus73]

Work is called "work" for a reason, right?

Hopefully one can get some degree of pleasure and mastery from "work" but I have always cringed at the term "calling" or any other labels given to doing and managing your "professional work"....in which making money is the key factor/ingredient within the definition of the word.

I would reframe it as creating value for others, which then generates money. But money is just a symbol for the value provided. Thinking about the value you provide vs the money you generate helps get it closer to a calling. Definitely more beneficial doing this work for society than programming a Facebook algorithm that increases ad views to purchase conversions by 0.0012% while making users more outraged and depressed.

 

[splik]

I know multiple people who regretted going into psych and during residency we had several people who switched specialties (to peds, IM, neuro) and I know some who switched to derm, as well as people who left medicine altogether. Going by the numbers, there is a high level of satisfaction in psychiatry compared to other medical specialties but I have not found it to be the case that most psychiatrists love it. Most of my psychiatrist friends work part time, and I think they love the flexibility to do that. I do have some colleagues who want to practice forever. I actually do love what I do, but I also cannot wait to retire! I think anyone who goes into psychiatry thinking they're gonna make bank is probably not going to be happy. You can definitely be decently compensated in psychiatry but by the numbers, it is one of the lowest paying specialties in general. I have colleagues in forensics who clear over a million a year, but the median salary for a full time psychiatrist is under 290k with most falling in the 250-350k range.

I tend to think the people who are particularly satisfied are people like me who expected to make very little and were pleasantly surprised (when I was applying for residency, the academic rate was about 125k). But compensation in specialities is something at ebbs and flows, and it just happens this is a particularly golden era not seen since the early 1970s. That is absolutely not going to last forever.

 

[erg923]

I would reframe it as creating value for others, which then generates money. But money is just a symbol for the value provided. Thinking about the value you provide vs the money you generate helps get it closer to a calling. Definitely more beneficial doing this work for society than programming a Facebook algorithm that increases ad views to purchase conversions by 0.0012% while making users more outraged and depressed.

This is fair.

I was just trying to make sure we don't get into too much "fusion." "You"... are not a psychiatrist, right? This is your job. Fusion of job/profession and identity (e.g. "calling") can be very unhealthy, and is exactly why mental health interventionists are often needed to serve otherwise high functioning professionals/physicians/CEOs.

 

[comp1]

I think psychiatrists are less likely to be fused to their profession than other physicians. And to the poster above at the end of their CAP fellowship feeling meh...residency is NOT practice! Hopefully you find actual practice much, much better. It certainly is for me. I would strongly recommend against any more fellowships for you.

 

[Bartelby]

How much?

A rough idea based on my observations, if you make money a priority (for example, not going into low-paid academic roles):

$300k: pretty standard, doable with a 40-hour week and reasonable working conditions.
$400k: still pretty easy. Add $8k worth of monthly moonlighting or a side job to the $300k job and you are there, or extend hours beyond they typical 40.
$500k: in this range and above you likely need to be doing something different. That could be running a private practice where others are also generating revenue for you. It could be a cash pay private practice with high rates. It could be doing a lot of forensic work at high hourly rates. It could be leadership roles in certain systems. It could be doing large volumes of clinical care, likely of dubious quality. In short, though, going over about $500k is pretty unusual and would not be typical for most clock-in and clock-out employed positions.

 

[painballer27]

A rough idea based on my observations, if you make money a priority (for example, not going into low-paid academic roles):

$300k: pretty standard, doable with a 40-hour week and reasonable working conditions.
$400k: still pretty easy. Add $8k worth of monthly moonlighting or a side job to the $300k job and you are there, or extend hours beyond they typical 40.
$500k: in this range and above you likely need to be doing something different. That could be running a private practice where others are also generating revenue for you. It could be a cash pay private practice with high rates. It could be doing a lot of forensic work at high hourly rates. It could be leadership roles in certain systems. It could be doing large volumes of clinical care, likely of dubious quality. In short, though, going over about $500k is pretty unusual and would not be typical for most clock-in and clock-out employed positions.

I see. Thanks. How common is it for private practice psychiatrists to employ others, such as NPs or therapists?
Also would it be possible to reach the 600k range doing inpatient jobs if you’re highly efficient?

 

[Psychresy]

A rough idea based on my observations, if you make money a priority (for example, not going into low-paid academic roles):

$300k: pretty standard, doable with a 40-hour week and reasonable working conditions.
$400k: still pretty easy. Add $8k worth of monthly moonlighting or a side job to the $300k job and you are there, or extend hours beyond they typical 40.
$500k: in this range and above you likely need to be doing something different. That could be running a private practice where others are also generating revenue for you. It could be a cash pay private practice with high rates. It could be doing a lot of forensic work at high hourly rates. It could be leadership roles in certain systems. It could be doing large volumes of clinical care, likely of dubious quality. In short, though, going over about $500k is pretty unusual and would not be typical for most clock-in and clock-out employed positions.

My understanding from chatting with a few private practice docs is billing insurance can generate low 300s/hr. This would make 500k a year pretty easily attainable. Is this not something you've understood to be true?

 

[Bartelby]

My understanding from chatting with a few private practice docs is billing insurance can generate low 300s/hr. This would make 500k a year pretty easily attainable. Is this not something you've understood to be true?

I think low 300s per hour from billing insurance is very realistic. In many parts of the country it could be higher (for instance for two 99214 + 90833 encounters per hour). Still, that does not easily land you at 500k.

For a solo private practice example let's assume you work 46 hours per week. Keep in mind those six weeks off include all vacation, sick days, holidays, and anything else (in PP time off subtracts directly from your bottom line). Let's assume you fill 30 billable hours per week. I think that may be an ambitious estimate if you want to keep it to 40 hours of total time worked per week, but let's go with it. And let's assume all of your billed face-to-face time comes out to $330 per hour on average.

46 weeks per year x 30 hours per week x $330 per hour = $455,400.

Now subtract out rent, malpractice insurance, building utilities, furniture, accounting services, billing services, credit card processing fees, and any other costs. If you hire anyone to act as a secretary etc., then obviously subtract out that cost as well. Even if you keep all of that to 10% of your total collected, you are down to a net $400k. Not bad, but...

We are assuming that you have a 100% show rate for six hours of booked appointments each day. We also assume you maintain a perfect flow of work such that you always fill six hours each day but rarely have to go over dealing with work-ins, crisis issues etc. We also assume that in the remaining two hours each day you can do *everything else!* You can handle billing, accounting, calling to screen patients, responding to patient calls and messages, prior auths, record requests, talking with other physicians, talking with patients' therapists, and doing anything and everything else you need to do. If you can't handle all of that in two hours, then it isn't fair to call it an eight hour per day job. And obviously, your no-show rate will be higher than 0%.

So in short, private practice can pay quite well! In the range of low 300s per hour of face to face clinical time, though, you are going to have to grind hard to break $500k of take-home income. If you adjust those numbers up, though (let's say achieving $500 per hour or more in billing) then it gets easier to hit that $500k mark. But at that point, we are straying more into the "doing something different" category for many parts of the country (in some very high COL markets it might be realistic to bill somewhere close to that range for insurance).

 

[Bartelby]

I see. Thanks. How common is it for private practice psychiatrists to employ others, such as NPs or therapists?
Also would it be possible to reach the 600k range doing inpatient jobs if you’re highly efficient?

In my experience psychiatrists who employ others are in the minority, but it's not too uncommon. I would say maybe 10% or fewer of the psychiatrists I know have done something like that (though that is a rough guess).

 

[Stagg737]

I see. Thanks. How common is it for private practice psychiatrists to employ others, such as NPs or therapists?
Also would it be possible to reach the 600k range doing inpatient jobs if you’re highly efficient?

How common it is doesn't really matter, it's how realistic it is and in psychiatry it is not difficult if that's what you want to do. Plenty of docs and mid-levels are willing to take salary pay or a percentage of FFS if you're willing to do the admin work for them. The more important aspect there is how knowledgeable are YOU with the business/administrative side of things and are you willing to handle that work.

Is it possible to reach 600k doing inpatient? Yes. Is is realistic to make this while providing high quality care? No. You can certainly arrange to cover 2 units or see a high patient volume, but after a certain number of patients, every additional one you add will bring down the quality of care you can provide. The only way I see someone making 600k+ doing inpatient while maintaining a high level of quality care is in a specialty unit with almost exclusively private paying patients. Ie, celebrity or corporate residential substance or ED treatment facilities. However, outside of niche areas Bartleby's previous estimations are in-line with the jobs I've looked at.

 

[Candidate2017]

How is it possible that majority of the psychiatrist in SDN & Reddit are happy.

Like with selection bias, it's easy to find people who regret their field (IM, anesthesia, rads, peds, FM, etc).
But it's so hard to find psychiatrist who dislike their specialty - everyone seems to LOVE IT.

Most psychiatrists are happy because they are... happy, regardless of whether they love psychiatry. It does help that it is easier in psychiatry to work less or find different practice environments and different patient populations.

I see. Thanks. How common is it for private practice psychiatrists to employ others, such as NPs or therapists?
Also would it be possible to reach the 600k range doing inpatient jobs if you’re highly efficient?

Don't choose psychiatry based on hours and money.

Psychiatry is generally not an "efficient" specialty. There are reasons ($$$$) why hospitals choose to invest in, open, and advertise their fancy heart and cancer centers/clinics, rather than psych clinics/wards. To be efficient in psychiatry requires a lot of boundaries, experience, a good set up, and good staff. Or not caring about any outcomes.

If you are about efficiency, pick specialties where you do your work and are done. It doesn't even have to be a procedural specialty. For example, a hospitalist job is more efficient than psychiatry. Show up, round, short notes, put in orders, rarely any family meetings, go home or on the next hospital, handle any pages over the phone or EMR. During IM months in residency, after the initial rough transition, we'd marvel at the relative ease of managing a whole bunch of patients whose bodies are actively trying to die compared to a couple inpatient borderlines threatening suicide.

 

[Marasmus1]

A rough idea based on my observations, if you make money a priority (for example, not going into low-paid academic roles):

$300k: pretty standard, doable with a 40-hour week and reasonable working conditions.
$400k: still pretty easy. Add $8k worth of monthly moonlighting or a side job to the $300k job and you are there, or extend hours beyond they typical 40.
$500k: in this range and above you likely need to be doing something different. That could be running a private practice where others are also generating revenue for you. It could be a cash pay private practice with high rates. It could be doing a lot of forensic work at high hourly rates. It could be leadership roles in certain systems. It could be doing large volumes of clinical care, likely of dubious quality. In short, though, going over about $500k is pretty unusual and would not be typical for most clock-in and clock-out employed positions.

I have to say though that ''40 hour work weeks'' vary significantly. I have seen 60 hours of workload squeezed in 40 hours and marketed as 1.0 FTE.

In academia, based on my experience, it is the vices versa where 25 to 30 hours of actual ''work'' stretched to 1.0 FTE and yes you get your paycut but many times at the expense of less intense work and many times flexibility. ( Exceptions are there and I am aware)

 

[FlowRate]

I have to say though that ''40 hour work weeks'' vary significantly. I have seen 60 hours of workload squeezed in 40 hours and marketed as 1.0 FTE.

In academia, based on my experience, it is the vices versa where 25 to 30 hours of actual ''work'' stretched to 1.0 FTE and yes you get your paycut but many times at the expense of less intense work and many times flexibility. ( Exceptions are there and I am aware)

I find it interesting to hear about academic jobs being more cush on average. One of the many things that pushed me away from academic jobs was both the long hours and busy work of most of my CL and outpatient attendings. A few of the inpatient attendings (who were on a much more generous legacy institutional contract) and some of the more senior part time CL attendings could carve themselves a pretty sweet gig, however.

 

[Marasmus1]

I find it interesting to hear about academic jobs being more cush on average. One of the many things that pushed me away from academic jobs was both the long hours and busy work of most of my CL and outpatient attendings. A few of the inpatient attendings (who were on a much more generous legacy institutional contract) and some of the more senior part time CL attendings could carve themselves a pretty sweet gig, however.

To me, both the long hours and busy clinical work is definition of non-academic job and though I observed these jobs being marketed under academic umbrella, they do not necessarily have the pay cut. I was offered assistant professor of psychiatry ''academic job'' with total compensation of 340k annually but expected to cover busy inpatient floors once a month and average 12 kids in the inpatient daily. On top of that academic expectations such as teaching residents didactics , supervising fellows while providing aforementioned clinical work.

The current academic gig I am about to sign gives me flexibility to schedule my follow ups an hour long, no RVU expectations and give me separate admin and teaching time.

 

[splik]

In academia, based on my experience, it is the vices versa where 25 to 30 hours of actual ''work'' stretched to 1.0 FTE and yes you get your paycut but many times at the expense of less intense work and many times flexibility. ( Exceptions are there and I am aware)

unfortunately, most true academic jobs these days have lots of work. The volume of patients is typically much less but when you add in preparing curricula and lectures, writing papers, reviewing papers, serving on committees, editorial work, and the myriad of other things that one is expected to do it is usually a lot more than 40hrs. There are some cushy jobs out there (and I suppose you could forgo all the fluff and not get promoted or advance in your career) but the golden era where one could sit around doing nothing as a psychiatry clinician-educator have gone the way of the dodo, a victim of the hospital c-suite.

 

[Marasmus1]

unfortunately, most true academic jobs these days have lots of work. The volume of patients is typically much less but when you add in preparing curricula and lectures, writing papers, reviewing papers, serving on committees, editorial work, and the myriad of other things that one is expected to do it is usually a lot more than 40hrs. There are some cushy jobs out there (and I suppose you could forgo all the fluff and not get promoted or advance in your career) but the golden era where one could sit around doing nothing as a psychiatry clinician-educator have gone the way of the dodo, a victim of the hospital c-suite.

I can definitely see this happening. As a matter of fact during the interviews my chairman told me ''If you want to be professor in the next two decades, you should be willing to work minimum 50 hours a day''. However, not everybody needs to advance in academic ranks. I have seen assistant professors at age 65 in academia

 

[mistafab]

I am satisfied.

 

[painballer27]

I am satisfied.

Could you elaborate on some of the sources of your satisfaction in psychiatry?

 

[mistafab]

Could you elaborate on some of the sources of your satisfaction in psychiatry?

I was satisfied before psychiatry - which may point to a personality bias that psychiatrists may or may not share.

 

[calvnandhobbs68]

I can definitely see this happening. As a matter of fact during the interviews my chairman told me ''If you want to be professor in the next two decades, you should be willing to work minimum 50 hours a day''. However, not everybody needs to advance in academic ranks. I have seen assistant professors at age 65 in academia

Yeah this really depends on goals. I’ve also seen people just sit at “instructor” or “assistant professor” level for a while and then just bail to private practice after getting some experience or use the academic job for benefits while doing extra stuff on the side. I’ve seen people definitely negotiate things like a day of “admin” time since most academic places won’t negotiate much on pay.

 

[Merovinge]

I was satisfied before psychiatry - which may point to a personality bias that psychiatrists may or may not share.

I was satisfied before psychiatry but am substantially more satisfied being a psychiatrist. Going to work and making a palpable difference in someone's life on a daily basis while making a very respectable living that could cover my family were anything to happen to my wife and sleeping very well at night is a heck of a go. There are a lot of problems in modern medicine (see MD suicide rate for clear proof), but it's awfully satisfying for a number of people I know.

 

[Ellomate]

I was satisfied before psychiatry but am substantially more satisfied being a psychiatrist. Going to work and making a palpable difference in someone's life on a daily basis while making a very respectable living that could cover my family were anything to happen to my wife and sleeping very well at night is a heck of a go. There are a lot of problems in modern medicine (see MD suicide rate for clear proof), but it's awfully satisfying for a number of people I know.

I have no exposure to outpatient long term care. How is the patient relationship like? Do people get substantially get better and very grateful for your service? If that’s the case I can def see how satisfaction. Or are there a lot of refractory depression, chronic low functioning schizo, difficult personality disorder, that burns you out on some weeks?

 

[nexus73]

I have no exposure to outpatient long term care. How is the patient relationship like? Do people get substantially get better and very grateful for your service? If that’s the case I can def see how satisfaction. Or are there a lot of refractory depression, chronic low functioning schizo, difficult personality disorder, that burns you out on some weeks?

There’s a lot of chronic symptoms, but those patients do better seeing you. And I only realized this after leaving a clinic and discharging people I thought had made no improvement despite numerous medication trials. They would almost all tell me how much of a difference I made in there life, which was surprising as PHQ9 scores hadn’t changed much.

 

[NickNaylor]

Yeah this really depends on goals. I’ve also seen people just sit at “instructor” or “assistant professor” level for a while and then just bail to private practice after getting some experience or use the academic job for benefits while doing extra stuff on the side. I’ve seen people definitely negotiate things like a day of “admin” time since most academic places won’t negotiate much on pay.

Definitely the case at my institution. The "promotion" to assistant professor from instructor here is essentially automatic and has no meaningful benefits. Relatively few people progress beyond that, and no one except for the department seems to care all that much.

 

[ObsequiousAplomb]

I have no exposure to outpatient long term care. How is the patient relationship like? Do people get substantially get better and very grateful for your service? If that’s the case I can def see how satisfaction. Or are there a lot of refractory depression, chronic low functioning schizo, difficult personality disorder, that burns you out on some weeks?

In private practice there are not going to be very many low functioning patients with schizophrenia, as those would be better served by systems with more resources to help them. As a rule, if someone has any condition that you can't adequately manage you'll probably refer them to the appropriate level of care for their condition. They may or may not come back once they've stabilized.

In general, you keep seeing the people who are gaining benefit and the ones who don't want to keep seeing you either see someone else or see nobody. So you'll see loads of people who improved drastically and are very grateful and want to continue treatment to maintain their improvements. You'll see a fair number of people who experience some benefit and wish to continue in treatment with you to either maintain that improvement or work towards further improvement.

You'll see some people who seemingly just want to come to your office and complain without ever seeming to improve. Those people either are improving to some degree that you can't see, really are not improving (and therefore not getting worse), or are gradually getting worse. Whatever their trajectory, once you realize that's what's going on it doesn't really bother you as much. After all, they're the patient and it's the patient's role to suffer, not yours. Why would you let their suffering ruin your day / career / marriage / family / hobbies? Sure, it's sad and angering and can make you feel inadequate, but I imagine the same thing is true for any other specialty in medicine that manages people who are gradually decaying (so, all of them).


As to your question about the relationships, I enjoy them. I know people that I see quite well and find myself genuinely interested in their lives and struggles. In the course of doing my job I get to see them overcome some really heavy stuff. I get to learn all of their medical problems and see how they interact with their intrapsychic life. I get to learn how to modify my treatments to better balance their medical health and medical treatments. I get to see them in crisis and at resolution. I get to hear them questioning whether or not they should get married have children, etc, and then hear them talk about their satisfaction in marriage, singleness, and how they're reacting to seeing their children grow. I hear them brag about how they finally got that job / promotion / whatever and it's really quite a fun contrast to however they looked when we first met. If they don't improve that drastically, it's still an interesting perspective on their lives that I get to see while at work and then go home to my own family and friends. If they get worse then I do my professional best to try and help them out. They're usually quite grateful, especially the chronic schizophrenia patients who finally get an apartment or quit smoking or manage the discomfort of their perceptions. It's awesome, from my perspective.

 

[Merovinge]

I have no exposure to outpatient long term care. How is the patient relationship like? Do people get substantially get better and very grateful for your service? If that’s the case I can def see how satisfaction. Or are there a lot of refractory depression, chronic low functioning schizo, difficult personality disorder, that burns you out on some weeks?

Very different for me than most on these boards as I exclusively work with children and young adults. Lots of people that are routinely grateful for care. I actually get more thanks and gifts then my wife as a specialty surgeon who has horrendous call and works semi-terrible hours (for the record, I do find it backward how little people appreciate having their life saved acutely from medical illness, it's just an expectation these days).

 

[comp1]

People get better outpatient, but if you want to see dramatic improvement, do inpatient. Also, to see a lot of people who never get better, do inpatient.

 

[Ellomate]

In general, you keep seeing the people who are gaining benefit and the ones who don't want to keep seeing you either see someone else or see nobody. So you'll see loads of people who improved drastically and are very grateful and want to continue treatment to maintain their improvements. You'll see a fair number of people who experience some benefit and wish to continue in treatment with you to either maintain that improvement or work towards further improvement.

Wow I don't know why I haven't thought of this before. Basically the majority of the pts you see are those that want to be there. That's amazing.

Very different for me than most on these boards as I exclusively work with children and young adults. Lots of people that are routinely grateful for care. I actually get more thanks and gifts then my wife as a specialty surgeon who has horrendous call and works semi-terrible hours (for the record, I do find it backward how little people appreciate having their life saved acutely from medical illness, it's just an expectation these days).

that's very encouraging to hear!

 

[Shufflin]

Most psychiatrists are happy because they are... happy, regardless of whether they love psychiatry. It does help that it is easier in psychiatry to work less or find different practice environments and different patient populations.


Don't choose psychiatry based on hours and money.

Psychiatry is generally not an "efficient" specialty. There are reasons ($$$$) why hospitals choose to invest in, open, and advertise their fancy heart and cancer centers/clinics, rather than psych clinics/wards. To be efficient in psychiatry requires a lot of boundaries, experience, a good set up, and good staff. Or not caring about any outcomes.

If you are about efficiency, pick specialties where you do your work and are done. It doesn't even have to be a procedural specialty. For example, a hospitalist job is more efficient than psychiatry. Show up, round, short notes, put in orders, rarely any family meetings, go home or on the next hospital, handle any pages over the phone or EMR. During IM months in residency, after the initial rough transition, we'd marvel at the relative ease of managing a whole bunch of patients whose bodies are actively trying to die compared to a couple inpatient borderlines threatening suicide.

Respectfully disagree.

I sit on the executive board at a hospital. The federal government matches each Medicaid dollar creating a super multiplier effect which is lucrative for hospital systems, which is why you see international corporations like UHS thrive in the mental health facility domain. Psychiatry, like every medical specialty, presents revenue opportunities that really have nothing to do with the "efficiency" of it's practitioners. They are paid based on utilization reviews and justification for hospital days. Let's not conflate efficiency of practitioners with that of corporations/institutions.

Psychiatry is not inefficient. I can make the case that it is more efficient than several other specialties. I really don't understand this line of thought or logic. I see my patients and am done, and the amount of red tape is far less than that of my family medicine friends, for example.

Comprehensive mental health services that offer urgent care-inpatient-outpatient true wrap-around service models are lacking. Corporations invest heavily in psychiatry and mental health services. ie. the leading accounting firm KPMG International Limited is building out new psych facilities on the West Coast. UHS is taking over psych facilities on the East Coast, etc. These companies ARE advertising their psych services and facilities.

 

[splik]

Respectfully disagree.

I sit on the executive board at a hospital. The federal government matches each Medicaid dollar creating a super multiplier effect which is lucrative for hospital systems, which is why you see international corporations like UHS thrive in the mental health facility domain. Psychiatry, like every medical specialty, presents revenue opportunities that really have nothing to do with the "efficiency" of it's practitioners. They are paid based on utilization reviews and justification for hospital days. Let's not conflate efficiency of practitioners with that of corporations/institutions.

Psychiatry is not inefficient. I can make the case that it is more efficient than several other specialties. I really don't understand this line of thought or logic. I see my patients and am done, and the amount of red tape is far less than that of my family medicine friends, for example.

Comprehensive mental health services that offer urgent care-inpatient-outpatient true wrap-around service models are lacking. Corporations invest heavily in psychiatry and mental health services. ie. the leading accounting firm KPMG International Limited is building out new psych facilities on the West Coast. UHS is taking over psych facilities on the East Coast, etc. These companies ARE advertising their psych services and facilities.

UHS makes money by fraudulently billing, admitting patients who don't need admission, keeping patients for as long as insurance pays (their mantra is "don't leave days on the table"), kicking out pts as soon as insurance stops paying, and providing extremely limited programming and services. The margins for mental health in most spheres are very thin, particularly to provide high quality care. I'm not sure I would call this "thriving." It is not a coincidence that the companies most flush with cash in the mental health sphere are providing unethical or illegal care (see threads on cerebral) or the residential treatment industry (see Justice Department Announces Series of Cases to Combat Addiction Treatment Kickback Schemes in Southern California and 5 charged in $11.7 million California addiction treatment fraud scheme and Centers to Treat Eating Disorders Are Growing, and Raising Concerns (Published 2016)).

There is no doubt the PE has shown unprecedented interest in our field, and many people are looking at profitability but in general that is a very bad thing for our field.

 

[Candidate2017]

I sit on the executive board at a hospital. The federal government matches each Medicaid dollar creating a super multiplier effect which is lucrative for hospital systems, which is why you see international corporations like UHS thrive in the mental health facility domain. Psychiatry, like every medical specialty, presents revenue opportunities that really have nothing to do with the "efficiency" of it's practitioners. They are paid based on utilization reviews and justification for hospital days. Let's not conflate efficiency of practitioners with that of corporations/institutions.

Corporations invest heavily in psychiatry and mental health services. ie. the leading accounting firm KPMG International Limited is building out new psych facilities on the West Coast. UHS is taking over psych facilities on the East Coast, etc. These companies ARE advertising their psych services and facilities.

The view from the C-suite is different from the trenches.

When The Man advertises "mental health services", it’s not about patients seeing psychiatrists. It’s about The Man getting funding and billing for facility fees, NPs, SWs, execs, and everyone else except the "provider" a.k.a. psychiatrist. Will I get a cut of the facility fees, my own MA, a better secretary, a competent nurse, or even a 100 lb security guard? Heck no.

When The Man advertises "orthopedic center", the patient gets an orthopedic surgeon, not an NP or social worker. And the surgeon demands and gets competent nurses, techs, assistants, a state of the art OR, the latest surgical equipment. And better pay.

UHS? They are as efficient as cancer, like any for profit corporation in the "mental heath space". A bunch of 9-fiugre settlements for allegations of fraudulent billing (services not rendered), fraudulently extending length of stay for those with good insurance, using patients as unlicensed inpatient therapists, etc. But still going strong and expanding. I hear some UHS-run psych wards are offering "providers" $100 per patient. Efficient indeed.

 

[smalltownpsych]

The view from the C-suite is different from the trenches.

When The Man advertises "mental health services", it’s not about patients seeing psychiatrists. It’s about The Man getting funding and billing for facility fees, NPs, SWs, execs, and everyone else except the "provider" a.k.a. psychiatrist. Will I get a cut of the facility fees, my own MA, a better secretary, a competent nurse, or even a 100 lb security guard? Heck no.

When The Man advertises "orthopedic center", the patient gets an orthopedic surgeon, not an NP or social worker. And the surgeon demands and gets competent nurses, techs, assistants, a state of the art OR, the latest surgical equipment. And better pay.

UHS? They are as efficient as cancer, like any for profit corporation in the "mental heath space". A bunch of 9-fiugre settlements for allegations of fraudulent billing (services not rendered), fraudulently extending length of stay for those with good insurance, using patients as unlicensed inpatient therapists, etc. But still going strong and expanding. I hear some UHS-run psych wards are offering "providers" $100 per patient. Efficient indeed.

Efficient like cancer. Ain’t that the truth. Arguably worse than cancer, because they have a lot of people convinced that they are making things better.

 

[nexus73]

Re: UHS. Two anecdotes of very solid psychiatrists (like very competent and efficient, but not efficient bad) from two different UHS hospitals. I assumed these types of docs would be perfect fits because they are sort of no nonsense practical guys who understand it's a business. One lasted 1 year because he was as he put it "one of the four D's: dumb, desperate, divorced, or in debt." And UHS paid the most in the region. The other doc lasted 3 months before bailing saying it wasn't a safe place to work. And this was a guy who would see 20 adults and 10 child patients per day on weekend cross cover at his previous hospital and he thought UHS was bad So, I can't imagine ever working at UHS personally. I've also had patients go there and tell me the groups were just a nurse giving them a handout to read about DBT skills, and the patients all sat in silence in the group room reading to themselves.

 

[Shufflin]

I agree these are not the most ethical entities, to put it mildly.

We see decent margins at our hospital system (without fraud for inquiring minds).