seeking advice for future job prospects...

[justordinary]

Hi, so I'm a pretty young psychiatrist, finished residency then signed my first attending job at an academic institution in Northeast...
Over this short amount of time that I've been practicing as an attending, I've come to realize a few things and was seeking advice of other psychiatrists for my future career...

1) institutions don't care about you as an individual so I've always gotta have an exit plan
2) administrators do not care about patient care, it's all about $$ so they will hire NP in your place.
3) more and more job positions open for NPs and less and less for MDs
4) It's almost impossible to climb up the ladder at an academia with just doing good clinical work. you've gotta be in bed with admin even if you don't agree with their policy, publish papers (I'm not into research, especially if it means dedicating my weekend hours without any extra compensation), etc...
5) politics is crazy...

All of these things are very disheartening to me.....
I've thought about joining a private institution however I've heard their admin are even worse than academia admin.
I've thought about opening PP but NPs are opening PP like dandelions and patients don't know the different between NP and MD, so who will come to see me with this steep competition?
I honestly feel lost, as I find myself not happy in academia but do not know where to go from here...
Please help....

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[nexus73]

I'd wonder what it is you like about academics. If you just like teaching, there are many residency programs at community/regional hospitals, that aren't academic. You could teach residents and avoid the demand to publish, and likely less political BS too. Maybe that would be a better fit. As to the administrators being better worse, I think it is going to vary at each institution. I'm in the western US, and I think in more medium sized cites and smaller, things are better for psychiatrists because the shortage is even more pronounced, maybe think about leaving the large metro area, if that's where you currently are.

 

[Psychresy]

I hate to say this but as a senior resident who's going to start looking for jobs in earnest in about a year...the current state of the field based on recent threads is incredibly disheartening. Almost makes me wonder if I should shift gears and consider a second residency.

 

[hamstergang]

I hate to say this but as a senior resident who's going to start looking for jobs in earnest in about a year...the current state of the field based on recent threads is incredibly disheartening. Almost makes me wonder if I should shift gears and consider a second residency.

Eh, only those who have complaints tend to post about them. I've loved my job over the past 5 years and feel well supported by administration. I'm getting paid well without pressure to see more patients. Recruiters keep reaching out to me about other job opportunities. I don't know of any local private practice that are struggling.

 

[Sushirolls]

I hate to say this but as a senior resident who's going to start looking for jobs in earnest in about a year...the current state of the field based on recent threads is incredibly disheartening. Almost makes me wonder if I should shift gears and consider a second residency.

NO. Don't. Things are not that bad. Don't change to anything else.

 

[Sushirolls]

I'm in the middle of the dandelion fields. It's still worth it to open your private practice. You have the freedom to practice how you wish. No admin. You are the admin. There are still plenty of places, right now, that you can open up shop and be full faster than you expected. Even if you are in the pockets like I am that are thick with dandelions, its okay, it'll take time, but you are living where you want to live and have all the other flexibilities to take time for you when you want.

Make a change before you get burned out. But if you are just ruminating on future what ifs, but are actually happy with your job, then stay the course, and keep on doing what you are doing.

I recently explored/scouted one area to move to, with THE BOSS, and it would have been bursting in Psych need. I would have been full in less than 3 months. However, THE BOSS and I just didn't want to move.

 

[AD04]

OP, why should anyone hire you over one of the many psychiatrists or NPs in the area? If you cannot answer that question, you don't deserve higher pay. No one pays more unless they have to.

the current state of the field based on recent threads is incredibly disheartening

People who are doing well don't come to the forum asking for help. There are psychiatrist out there making a lot of money. I am friends with a handful of them who make $500k or more per year.

 

[justordinary]

I'd wonder what it is you like about academics. If you just like teaching, there are many residency programs at community/regional hospitals, that aren't academic. You could teach residents and avoid the demand to publish, and likely less political BS too. Maybe that would be a better fit. As to the administrators being better worse, I think it is going to vary at each institution. I'm in the western US, and I think in more medium sized cites and smaller, things are better for psychiatrists because the shortage is even more pronounced, maybe think about leaving the large metro area, if that's where you currently are.

I thought about going PP right after residency, but figured I'm not ready to go solo. Figured academia would allow me to continue to learn as a young attending, and admin would be more civil compared to community hospitals. However, in all honesty I've been disappointed by academia. Admin still has control over attendings, admins's #1 priority is money, they even opened NP "residency" program. I see my fate in couple of years - either get in the same bed with admin, agree with 100% of what they do (even though they don't know anything about clinical work, they tell attendings what to do), and climb up the ladder. OR get pushed out. I like teaching residents and students however I can't stay just for the sake of teaching. I like clinical work - I like spending time with patients, building relationship with them, and devising treatment plans however I like doing clinical work on my own terms, not following the rules that admin set. So, the bottom line is I feel lost and I don't know what to do at this point.

 

[Sushirolls]

I thought about going PP right after residency, but figured I'm not ready to go solo. Figured academia would allow me to continue to learn as a young attending, and admin would be more civil compared to community hospitals. However, in all honesty I've been disappointed by academia. Admin still has control over attendings, admins's #1 priority is money, they even opened NP "residency" program. I see my fate in couple of years - either get in the same bed with admin, agree with 100% of what they do (even though they don't know anything about clinical work, they tell attendings what to do), and climb up the ladder. OR get pushed out. I like teaching residents and students however I can't stay just for the sake of teaching. I like clinical work - I like spending time with patients, building relationship with them, and devising treatment plans whoever I like doing clinical work on my own terms, not following the rules that admin set. So, the bottom line is I feel lost and I don't know what to do at this point.

So shuck the yoke of admin. Go open your own practice. You've learned what you can from an employed job, now go start your own. Have fun. Got questions, post on SDN. Or some gravitate towards some of the Facebook specific groups for their Q&A.

Give yourself a pat on the back, you came to these conclusions far sooner than I. I spent several years at a Big Box shop thinking it was true, that the mission statement to serve the greater community would be worked towards and the non-profit status was valid, but the slowed pace of change was because of tight budgets as they were the victim suffering from the oppression of government and insurance... Yeah, nope. They just knew how to oppress their 'providers' well, and had an army of lawyers, or even standby lawfirms for extra busy times, to swat down any issues that popped up.

 

[justordinary]

OP, why should anyone hire you over one of the many psychiatrists or NPs in the area? If you cannot answer that question, you don't deserve higher pay. No one pays more unless they have to.



People who are doing well don't come to the forum asking for help. There are psychiatrist out there making a lot of money. I am friends with a handful of them who make $500k or more per year.

I find the question "why anyone should hire MD over NP" a sad reflection of our current field. It is very disheartening that is even a question - because this questions reflects that the level of training, hours, dedication etc that physicians put into learning psychiatry is almost meaningless in the present situation.

 

[nexus73]

I thought about going PP right after residency, but figured I'm not ready to go solo. Figured academia would allow me to continue to learn as a young attending, and admin would be more civil compared to community hospitals. However, in all honesty I've been disappointed by academia. Admin still has control over attendings, admins's #1 priority is money, they even opened NP "residency" program. I see my fate in couple of years - either get in the same bed with admin, agree with 100% of what they do (even though they don't know anything about clinical work, they tell attendings what to do), and climb up the ladder. OR get pushed out. I like teaching residents and students however I can't stay just for the sake of teaching. I like clinical work - I like spending time with patients, building relationship with them, and devising treatment plans however I like doing clinical work on my own terms, not following the rules that admin set. So, the bottom line is I feel lost and I don't know what to do at this point.

I think there's a lot of inpatient jobs at non-profit hospitals where you can get paid by RVUs and basically do what you want clinically, with or without a psych residency for teaching.

 

[dl2dp2]

You need to open a part-time cash private practice right now. Once you've done it you won't be so lost. It's really that simple.

 

[dl2dp2]

Give yourself a pat on the back, you came to these conclusions far sooner than I. I spent several years at a Big Box shop thinking it was true, that the mission statement to serve the greater community would be worked towards and the non-profit status was valid, but the slowed pace of change was because of tight budgets as they were the victim suffering from the oppression of government and insurance... Yeah, nope. They just knew how to oppress their 'providers' well, and had an army of lawyers, or even standby lawfirms for extra busy times, to swat down any issues that popped up.

This, 1000%.

 

[watto]

Second, third, and fourth the PP suggestion. If you like academics, throw your energies into learning all you can about a niche area of psychiatry so you can continue lifelong learning in the area, establish a network of colleagues, and become a prized referral source.

And start digging on the private practice threads here. There is virtually no unanswered PP question on these boards.

 

[Stagg737]

I hate to say this but as a senior resident who's going to start looking for jobs in earnest in about a year...the current state of the field based on recent threads is incredibly disheartening. Almost makes me wonder if I should shift gears and consider a second residency.

Already been said, but the state of the field is still looking pretty nice. Compared to other fields there's more flexibility and job security with more earning potential than many other fields. Even with all the problems, psych is still looking good for the foreseeable future. Take a deep breath, then take that doom and gloom back to the anesthesia or radiology forums.

I find the question "why anyone should hire MD over NP" a sad reflection of our current field. It is very disheartening that is even a question - because this questions reflects that the level of training, hours, dedication etc that physicians put into learning psychiatry is almost meaningless in the present situation.

This is a reflection of most non-procedural areas of medicine now. Honestly though, it's a very fair question. If a physician can't tell why they bring more value or expertise to a position than an NP, then why should they be paid more? Heck, if that's the case then why did they bother taking the physician route at all?

 

[Splenda88]

Already been said, but the state of the field is still looking pretty nice. Compared to other fields there's more flexibility and job security with more earning potential than many other fields. Even with all the problems, psych is still looking good for the foreseeable future. Take a deep breath, then take that doom and gloom back to the anesthesia or radiology forums.




This is a reflection of most non-procedural areas of medicine now. Honestly though, it's a very fair question. If a physician can't tell why they bring more value or expertise to a position than an NP, then why should they be paid more? Heck, if that's the case then why did they bother taking the physician route at all?

Radiology is looking extremely good right now

The doom and gloom are in anesthesia, EM, radonc and pathology.

 

[Merovinge]

I hate to say this but as a senior resident who's going to start looking for jobs in earnest in about a year...the current state of the field based on recent threads is incredibly disheartening. Almost makes me wonder if I should shift gears and consider a second residency.

There is a hugggge selection bias in posts you are seeing, and specifically one person recently who is clearly changing the median post about this. I recently applied to several jobs in a major metro and received many offers at or around 300k employed with bennies for normal fulltime work weeks. A few of these jobs were a bit meatgrindery for my tastes but multiple had very reasonable case loads including the one I signed onto. There are also swathes of very successful PP folks in the area as well. I can't speak to other parts of the country, but I don't believe my bank account shows any signs of bias.

 

[justordinary]

So shuck the yoke of admin. Go open your own practice. You've learned what you can from an employed job, now go start your own. Have fun. Got questions, post on SDN. Or some gravitate towards some of the Facebook specific groups for their Q&A.

Give yourself a pat on the back, you came to these conclusions far sooner than I. I spent several years at a Big Box shop thinking it was true, that the mission statement to serve the greater community would be worked towards and the non-profit status was valid, but the slowed pace of change was because of tight budgets as they were the victim suffering from the oppression of government and insurance... Yeah, nope. They just knew how to oppress their 'providers' well, and had an army of lawyers, or even standby lawfirms for extra busy times, to swat down any issues that popped up.

Thank you for your insight. How did you market yourself amongst field of dandelions? From my experience, 99.999% of patients did not know the difference between a psychiatrist and psych NP, they would refer to NP as "my psychiatrist" or "my doctor" and NPs also introduce themselves as "im dr so and so." I find it sad that our field does not provide us with anything concrete to market ourselves - i mean, i can say im "better trained in pharmacotherapy, diagnositic skills, and also do therapy" however who provides us with objective measurement of "better outcome"?

Also, this question is for everybody on the forum - do you guys think there is better job safety with opening PP and competing with NP dandelions, or better job safety in staying with big box shop and risk getting fired/replaced in the future?

 

[jbomba]

Thank you for your insight. How did you market yourself amongst field of dandelions? From my experience, 99.999% of patients did not know the difference between a psychiatrist and psych NP, they would refer to NP as "my psychiatrist" or "my doctor" and NPs also introduce themselves as "im dr so and so." I find it sad that our field does not provide us with anything concrete to market ourselves - i mean, i can say im "better trained in pharmacotherapy, diagnositic skills, and also do therapy" however who provides us with objective measurement of "better outcome"?

I often correct the patient and let them know their NP is just that, a nurse.

 

[jbomba]

So shuck the yoke of admin. Go open your own practice. You've learned what you can from an employed job, now go start your own. Have fun. Got questions, post on SDN. Or some gravitate towards some of the Facebook specific groups for their Q&A.

Give yourself a pat on the back, you came to these conclusions far sooner than I. I spent several years at a Big Box shop thinking it was true, that the mission statement to serve the greater community would be worked towards and the non-profit status was valid, but the slowed pace of change was because of tight budgets as they were the victim suffering from the oppression of government and insurance... Yeah, nope. They just knew how to oppress their 'providers' well, and had an army of lawyers, or even standby lawfirms for extra busy times, to swat down any issues that popped up.

In the times of more lean practices, any idea what general overhead might be for a practice? If one were to see 50% of patients tele, I would imagine that would cut down on office space costs. Are we looking at 10-20% of collected revenue as going toward overhead?

 

[justordinary]

I often correct the patient and let them know their NP is just that, a nurse.

haha maybe I should start doing that... I dunno why but I feel so guilty (?) correcting the patients because at my institution you are hammered with "NPs are your colleagues who are equal to you" slogan... NP residents go around introducing themselves as "I'm a psych resident" Maybe i'm being brainwashed by my institution

 

[justordinary]

In the times of more lean practices, any idea what general overhead might be for a practice? If one were to see 50% of patients tele, I would imagine that would cut down on office space costs. Are we looking at 10-20% of collected revenue as going toward overhead?

I'm trying to research about this with all the resources I can find (Which is googling and sdn), I figured I would start with PP telepsych to keep overhead low, then sublease from somebody's office one day a week then see how it goes.. Or maybe sublease right from the beginning. I probably won't work 100% at an office as that would be too much overhead with rent. I also can't imaging working telepsych 100% indefinitely as I do feel that some patient benefit more from being seen in the office.
Other than rent, I'd have to pay for EMR, malpractice, opening up LLC (or PCCL), hiring a lawyer. I can get health insurance through family so I don't need that benefit to stay in big box shop. I guess I'll have to save up for my own retirement as I'd be losing the retirement benefit but I do hope I'll end up making more money so it will at least match the retirement contribution i'm getting through my employer.

 

[dl2dp2]

Thank you for your insight. How did you market yourself amongst field of dandelions? From my experience, 99.999% of patients did not know the difference between a psychiatrist and psych NP, they would refer to NP as "my psychiatrist" or "my doctor" and NPs also introduce themselves as "im dr so and so." I find it sad that our field does not provide us with anything concrete to market ourselves - i mean, i can say im "better trained in pharmacotherapy, diagnositic skills, and also do therapy" however who provides us with objective measurement of "better outcome"?

Also, this question is for everybody on the forum - do you guys think there is better job safety with opening PP and competing with NP dandelions, or better job safety in staying with big box shop and risk getting fired/replaced in the future?

Nobody except bureaucrats cares about "objective outcome". Does a Gucci bag has a better objective outcome than a Walmart bag? Quality is a lot more than the average. It's also about variance. NPs have a much higher variance in quality--this aspect should be clear as water to everyone.

There are a large number of threads on this forum on how to market your PP. I would start there. Then I would talk to people who have private practices in the community and reach out and talk to them. Don't be shy and anxious. I find in my experience that many senior psychiatrists are more than happy to mentor junior physicians.

In the times of more lean practices, any idea what general overhead might be for a practice? If one were to see 50% of patients tele, I would imagine that would cut down on office space costs. Are we looking at 10-20% of collected revenue as going toward overhead?

10-20% is reasonable. In a good year it could be less than 10%. If you hire a lot of staff the margin could be lower and you'll end up with a higher EBITA. There's not really a strict rule on this.

 

[Sushirolls]

In the times of more lean practices, any idea what general overhead might be for a practice? If one were to see 50% of patients tele, I would imagine that would cut down on office space costs. Are we looking at 10-20% of collected revenue as going toward overhead?

Under 40% you're doing okay, meh.
Under 30% is solid
Under 20% hit cruise control and pat yourself on the back.
Under 10% buy bling and sing narcissistic ballades about yourself

I'm still in building stages of my practice with a higher overhead due to higher lease, and I was at 37.5% last Quarter. I anticipate in future getting this down to 20-25% for sure.

Big variables are cash vs insurance based. This impacts number of staff or lack of staff.
What kind of lease do you have?
What is your gross income ability? I.e. I'm not billing as much 90833 so that suppresses income.
What type of marketing and how much are you spending if at all?
What types of state specific taxes are there if at all?

 

[Stagg737]

Radiology is looking extremely good right now

The doom and gloom are in anesthesia, EM, radonc and pathology.

True, but last time I was in the rads forum it was all about how their jobs are being outsourced to remote docs and how other fields are doing procedures that IR often does.

Also, this question is for everybody on the forum - do you guys think there is better job safety with opening PP and competing with NP dandelions, or better job safety in staying with big box shop and risk getting fired/replaced in the future?

Private practice 100%. The best job security is to be your own boss.

haha maybe I should start doing that... I dunno why but I feel so guilty (?) correcting the patients because at my institution you are hammered with "NPs are your colleagues who are equal to you" slogan... NP residents go around introducing themselves as "I'm a psych resident" Maybe i'm being brainwashed by my institution

You are, the argument that we're "equal" is a joke. They may be our colleagues, but anyone arguing equality needs a reality check. I mean, some states require dog groomers to have more "clinical" hours than NPs. There are some good NPs out there, but there's also an ocean of terrible ones and I find the latter is more often true than the former. Frankly, I'm still a resident but if there was a psych NP/NP "resident" introducing themselves as a psych resident, I'd be reporting it to my attending and PD.

 

[dl2dp2]

Hi Sushirolls, I've been following your PP thread - it looks like you rented a good amount of space because you wanted to do ECT, if I'm not mistaken? how is it working out? I'm nowhere as ambitious as you are and my dreams are smaller (hope it gets bigger in the future if things work out XD) do you think starting out a PP as telepsych to keep overhead low is a feasible idea? or do you think it's too risky as I don't get to see patients in the office?

Rent a part-time office.

With regard to job safety: PP is >>>>>>> employment in this regard. People neglect what I call "interpersonal risk" in working with a large organization. Income fluctuation as a risk pales in comparison to interpersonal risk. It's highly likely that in organizations at some point you'll be managed by people who are dumber and less capable than you are, and you are paid less than people who are less competent. It's highly likely that institutions have values that don't align with yours and you have no ownership to change any of this. These issues don't exist if you own your business. The only focus is to find and serve your customers.

Furthermore, in psychiatry, the income fluctuation can be hedged by taking 1099 jobs.

That said, some people enjoy the gaming aspects of working with large organizations: to make this more explicit, to get the right people to like you. To do this well you need to have some financial resources to back yourself up: as with any game, playing institutional politics games can be risky (and fun). Furthermore, if you want to advance (and have a secure job) in a large organization, enjoying this game is essentially a requisite.

 

[justordinary]

Under 40% you're doing okay, meh.
Under 30% is solid
Under 20% hit cruise control and pat yourself on the back.
Under 10% buy bling and sing narcissistic ballades about yourself

I'm still in building stages of my practice with a higher overhead due to higher lease, and I was at 37.5% last Quarter. I anticipate in future getting this down to 20-25% for sure.

Big variables are cash vs insurance based. This impacts number of staff or lack of staff.
What kind of lease do you have?
What is your gross income ability? I.e. I'm not billing as much 90833 so that suppresses income.
What type of marketing and how much are you spending if at all?
What types of state specific taxes are there if at all?

Hi Sushirolls, I've been following your PP thread - it looks like you rented a good amount of space because you wanted to do ECT, if I'm not mistaken? how is it working out? I'm nowhere as ambitious as you are and my dreams are smaller (hope it gets bigger in the future if things work out XD) do you think starting out a PP as telepsych to keep overhead low is a feasible idea? or do you think it's too risky as I don't get to see patients in the office?

1) lease: start at home to do telepsych then start subleasing 1-2 days a week about 6 months into practice is my goal
2) gross income: plan is to accept few insurance plans. hopefully get paid more than medicare rate (reimbursement in my area isn't too bad). I'm going to start with 60min eval and 30min follow-up with 99213/99214 + 09833
4) marketing: this is what I feel stuck with. I guess I'll sign up on psychology.com... and wait for insurance companies to refer me... and reach out to primary care offices, send them some gift basket with my name card on it....?? honestly I have no idea, I've never had to do this in my life
5) I live in northeast with pretty high tax rate... will have to talk to an accountant

 

[justordinary]

Rent a part-time office.

With regard to job safety: PP is >>>>>>> employment in this regard. People neglect what I call "interpersonal risk" in working with a large organization. Income fluctuation as a risk pales in comparison to interpersonal risk. It's highly likely that in organizations you'll be managed by people who are dumber and less capable than you are, and you are paid less than people who are less competent. It's highly likely that institutions have values that don't align with yours and you have no ownership to change any of this. These issues don't exist if you own your business. The only focus is to find and serve your customers.

Furthermore, in psychiatry, the income fluctuation can be hedged by taking 1099 jobs.

thanks for the insight. I thought I was being too sensitive/crazy for being so stressed out and dissatisfied by "interpersonal risk" which you pointed out. I just cannot get into the same bed with admins who don't know what they are doing in exchange for climbing up the ladder, I'd probably die prematurely from stress. I'll also try to look for 1099 job.

 

[dl2dp2]

thanks for the insight. I thought I was being too sensitive/crazy for being so stressed out and dissatisfied by "interpersonal risk" which you pointed out. I just cannot get into the same bed with admins who don't know what they are doing in exchange for climbing up the ladder, I'd probably die prematurely from stress. I'll also try to look for 1099 job.

Why not? Clueless admins are the easiest people to manipulate.

Many, MANY physician-led organizations have this history where it was initiated by non-physicians. Then physician leaders were able to basically convince the board of directors to fire the admins and take over themselves.

 

[justordinary]

Why not? Clueless admins are the easiest people to manipulate.

I've found that their main priority is exploiting physicians for their own agenda. AND patient care is NOT one of their priorities. They might be clueless in medicine but they are not clueless in perpetuating this messed up system and solidifying their own positions in healthcare. Maybe I'm biased but that was sadly my experience so far.

 

[dl2dp2]

I've found that their main priority is exploiting physicians for their own agenda. AND patient care is NOT one of their priorities. They might be clueless in medicine but they are not clueless in perpetuating this messed up system and solidifying their own positions in healthcare. Maybe I'm biased but that was sadly my experience so far.

Power play can be engaging. The reason you are "stressed" about it is that you don't have enough practice. Not everyone has the ambition to play these games, as you rightly pointed out. In that case, PP (or a mix of PP and 1099) is the best way to go if all you crave is job security.

Also, it's often hard for a new grad to power-play--although it is done. Once you bank a few millions it takes the "stress" down a notch and you might enjoy it more.

 

[justordinary]

Power play can be engaging. The reason you are "stressed" about it is that you don't have enough practice. Not everyone has the ambition to play these games, as you rightly pointed out. In that case, PP (or a mix of PP and 1099) is the best way to go if all you crave is job security.

Also, it's often hard for a new grad to power-play--although it is done. Once you bank a few millions it takes the "stress" down a notch and you might enjoy it more.

It's interesting to hear your side. I just have 0 desire to engage in powerplay as I do not find it meaningful... I want autonomy, satisfaction with my own clinical skills, job security, good amount of vacation time and high income. I guess PP is the way to go if these are the things I desire...
I've often wondered why people stay in big box shops and I guess if you have the personality that finds powerplay engaging, yes academia will provide you with that. And that's perfectly fine, it's just not for me. Also, do you mean bringing in donations/research grants when you say bank a few millions?

 

[dl2dp2]

It's interesting to hear your side. I just have 0 desire to engage in powerplay as I do not find it meaningful... I want autonomy, satisfaction with my own clinical skills, job security, good amount of vacation time and high income. I guess PP is the way to go if these are the things I desire...

Well, the power play is desirable if you want to "change the system" and scale. It's also desirable if you want to accomplish certain projects that derive meaning beyond the individual practitioner level (i.e. build a system, invest, innovate, research, etc.). Meaning in power-play primarily derives from intellectual property broadly defined, rather than the value of individual unit economics of service provided.

For your purposes, yes PP is the best way. There are actually few jobs in medicine that beat psych PP for this kind of life goal.

 

[justordinary]

Well, the power play is desirable if you want to "change the system" and scale. It's also desirable if you want to accomplish certain projects that derive meaning beyond the individual practitioner level (i.e. build a system, invest, innovate, research, etc.). Meaning in power-play primarily derives from intellectual property broadly defined, rather than the value of individual unit economics of service provided.

For your purposes, yes PP is the best way. There are actually few jobs in medicine that beat psych PP for this kind of life goal.

ahh yes... that does clarify my question. thanks!

 

[Sushirolls]

Well, the power play is desirable if you want to "change the system" and scale. It's also desirable if you want to accomplish certain projects that derive meaning beyond the individual practitioner level (i.e. build a system, invest, innovate, research, etc.). Meaning in power-play primarily derives from intellectual property broadly defined, rather than the value of individual unit economics of service provided.

For your purposes, yes PP is the best way. There are actually few jobs in medicine that beat psych PP for this kind of life goal.

I attempted this, and lost, lost hard.

 

[dl2dp2]

I attempted this, and lost, lost hard.

Well, I wouldn't beat yourself up on this. One, you decided to take a risk, and that says a lot about who you are--what is life but to take risks? Two, if you stayed in the game or played a different one next time, you might win. If I run a (better) big box shop I might hire you to be a medical director, and give you some equity etc. You'd spin a good story about your experience and you might get that job. I'm sure you learned a lot in the process.

 

[Sushirolls]

Hi Sushirolls, I've been following your PP thread - it looks like you rented a good amount of space because you wanted to do ECT, if I'm not mistaken? how is it working out? I'm nowhere as ambitious as you are and my dreams are smaller (hope it gets bigger in the future if things work out XD) do you think starting out a PP as telepsych to keep overhead low is a feasible idea? or do you think it's too risky as I don't get to see patients in the office?

1) lease: start at home to do telepsych then start subleasing 1-2 days a week about 6 months into practice is my goal
2) gross income: plan is to accept few insurance plans. hopefully get paid more than medicare rate (reimbursement in my area isn't too bad). I'm going to start with 60min eval and 30min follow-up with 99213/99214 + 09833
4) marketing: this is what I feel stuck with. I guess I'll sign up on psychology.com... and wait for insurance companies to refer me... and reach out to primary care offices, send them some gift basket with my name card on it....?? honestly I have no idea, I've never had to do this in my life
5) I live in northeast with pretty high tax rate... will have to talk to an accountant

I started out with goals for ECT, but that fizzled. ECT dream is dead. Won't revive it unless some day I hire on a fresh grad that still has enthusiasm that's not been tempered by Big Box shops. Doing a 100% telepsych form the start will have its own barriers and issues. I encourage doing an office first with a clear plan of transitioning patients to tele, or build up panel with both in person/tele patients, and once full, let every one know you are converting to 100% tele.

2) find out which insurance are worth accepting if any in your area.
1) get an office /sublease somewhere; convert to 100% tele in future after you have your sea legs doing this
3) Where did 3 go?
4) psychology today. Updated and accurate insurance company listings. Meet PCPs in person in their office and feed them, bring good food. SEnd mailings to therapists.
5) Yes, do talk to accountant.

 

[psyguru]

I have a forensic private expert witness practice and have two part-time clinical jobs (3 days a week). One is not too busy and the other has a high hourly and there are no real day-to-day issues. I believe a private expert witness practice is not as complicated as a private clinical practice. No insurance to deal with.

 

[Stagg737]

I want autonomy, satisfaction with my own clinical skills, job security, good amount of vacation time and high income. I guess PP is the way to go if these are the things I desire...

Sounds like private practice is perfect for you. You could find all the above in an employed PP position, but if you've got decent business/admin acumen starting your own practice puts you essentially in full control.

I've often wondered why people stay in big box shops and I guess if you have the personality that finds powerplay engaging, yes academia will provide you with that.

The above, but also the ability to not have to worry about the business or admin side of things beyond simple billing and charting. Some people are willing to jump through some hoops to be able to just go to work, see patients, chart, and then get their paycheck without having to deal with maintaining a practice or hunt down collections.

 

[justordinary]

I started out with goals for ECT, but that fizzled. ECT dream is dead. Won't revive it unless some day I hire on a fresh grad that still has enthusiasm that's not been tempered by Big Box shops. Doing a 100% telepsych form the start will have its own barriers and issues. I encourage doing an office first with a clear plan of transitioning patients to tele, or build up panel with both in person/tele patients, and once full, let every one know you are converting to 100% tele.

2) find out which insurance are worth accepting if any in your area.
1) get an office /sublease somewhere; convert to 100% tele in future after you have your sea legs doing this
3) Where did 3 go?
4) psychology today. Updated and accurate insurance company listings. Meet PCPs in person in their office and feed them, bring good food. SEnd mailings to therapists.
5) Yes, do talk to accountant.

oops, I think I combined the answers for #2 and 3 altogether... so I guess suggestion is start with sublease and in-person visits, then convert to telepsych even though in means more investment upfront.

I have a forensic private expert witness practice and have two part-time clinical jobs (3 days a week). One is not too busy and the other has a high hourly and there are no real day-to-day issues. I believe a private expert witness practice is not as complicated as a private clinical practice. No insurance to deal with.

how did you get to practice forensic private expert witness practice? this is something that I was never introduced to during residency...

 

[justordinary]

I attempted this, and lost, lost hard.

I've found bureaucracy's last motivation is to change - it's about keeping status quo and saving their a**. I'm not even going to attempt to do this at my institution because I know they'll come up with some insane reasons to get me fired, and I want to leave on my own terms. Plus, even if you do bring on change to an institution, at the end of the day you don't get to keep any of it because you are an "employee." I hope your PP is much more satisfying.

 

[dl2dp2]

I've found bureaucracy's last motivation is to change - it's about keeping status quo and saving their a**. I'm not even going to attempt to do this at my institution because I know they'll come up with some insane reasons to get me fired, and I want to leave on my own terms. Plus, even if you do bring on change to an institution, at the end of the day you don't get to keep any of it because you are an "employee." I hope your PP is much more satisfying.

I was recently in discussion with the CEO of a facility on exactly this issue. The common scenario for facilities around the country right now is a very low retention rate for psychiatrists, low morale, issues w.r.t. lifestyle expectations, and misalignment of expectations of what is reasonable and what isn't in care delivery. Especially as salaries are escalating, facilities find themselves unable to keep up with salary expectations of MDs in their own contract negotiations with payers if they want to retain, and yet owners are unwilling to give up ownership stakes, and hence we have a race to the bottom scenario where staffing gets replaced by NPs in service of margin, but the quality and the profit often decreases as a result (MDs are just more efficient).

To me this leads to undesirable inefficiencies, with service and personnel interruptions.

Nevertheless, the legacy CEOs and by extension the board of directors of treatment facilities are still expecting that they would be run like an old school company with employee loyalty but no ownership, whereas emerging companies are either hiring as tele-1099 with no expectation of long term engagement from day one, or more like a tech company, with concomitant physician ownership. The prevailing practice in the field is still very resistant to change, but I think it will eventually--at the moment, the equivalent of large single practice group for other specialties with physician ownership of underlying assets (i.e. ambulatory surgical centers, radiology centers, etc) in psychiatry *is* the solo practice.

 

[sloh]

People neglect what I call "interpersonal risk" in working with a large organization. Income fluctuation as a risk pales in comparison to interpersonal risk. It's highly likely that in organizations at some point you'll be managed by people who are dumber and less capable than you are, and you are paid less than people who are less competent. It's highly likely that institutions have values that don't align with yours and you have no ownership to change any of this. These issues don't exist if you own your business. The only focus is to find and serve your customers.

Furthermore, in psychiatry, the income fluctuation can be hedged by taking 1099 jobs.

Former W2 for a large organization and now a 1099 working for multiple employers. This is 100% true. I'll also add that when working for a large organization, they often really don't want you to rock the boat. It's not unusual that if you start raising concerns to the point where they see you as a nuisance, they will find ways to threaten your employment by pointing out any trivial "mistakes" you've made in the past.

That said, some people enjoy the gaming aspects of working with large organizations: to make this more explicit, to get the right people to like you. To do this well you need to have some financial resources to back yourself up: as with any game, playing institutional politics games can be risky (and fun). Furthermore, if you want to advance (and have a secure job) in a large organization, enjoying this game is essentially a requisite.

The time invested to successfully play these institutional politics generally isn't worth the financial ROI at all. Not when you compare it to how much more you can make as a 1099 and seeing more patients.

 

[nexus73]

The common scenario for facilities around the country right now is a very low retention rate for psychiatrists, low morale, issues w.r.t. lifestyle expectations, and misalignment of expectations of what is reasonable and what isn't in care delivery.

Can you expand on details about misalignment about care delivery and lifestyle expectations?

Also, is there a website, journal, forum, or podcast...some resource that hospital administrators go to to get a sense of the current market for physicians? It would be great to read a forum similar to this, but filled with CMOs and hospital executives complaining about how to retain psychiatrists...or complaining about how weird psychiatrists are etc etc.

 

[dl2dp2]

Can you expand on details about misalignment about care delivery and lifestyle expectations?

Also, is there a website, journal, forum, or podcast...some resource that hospital administrators go to to get a sense of the current market for physicians? It would be great to read a forum similar to this, but filled with CMOs and hospital executives complaining about how to retain psychiatrists...or complaining about how weird psychiatrists are etc etc.

Hospital CEOs expect that with $X out, they own you and you have to take X calls, see X patients, and when people are calling out sick you'd fill in the blank by default without expectation of extra pay, etc. etc. They also expect that you can see X patients in X minutes, without consideration to severity, no-show, or in the inpatient context, # of days per admission regardless of severity, complications, discharge planning, etc. The estimates of actual work amount and intensity are inaccurate, typically, if the organization is not physician-led.

This is a very common finding and well documented. Turnover is higher in non-physician-led facilities, and the burnout rate is higher.

These things are often not immediately obvious. For example, they might say we'll pay 300k to start, no weekend, no call. But then their usual roster of weekend people drop out, then all of a sudden it's can you "just" fill in this weekend until we find a replacement? Then it's 6 months later. Etc. etc. They know you'll eventually leave, but they'll try their luck because the longer you stay the more money they make off of you. You can try to sue them for breach of contract, which might succeed, but it's often expensive and risky.

The underlying driver of this is that the revenue-cost projections given to payers are often either outdated or too optimistic. Payers write contracts and pick facilities based on the lowest possible bid. Bids are therefore taken with the assumption of some margin where these types of things happen. When a new contract gets written the bids increase, and facilities get a new contract and go out there to scoop the physicians. This leads to personnel instability, which makes the cost estimates outdated again, etc. etc. In highly regulated industry, pricing is inelastic and don't respond to labor market supply-demand quickly. This manifests as a feeling of "exploitation" and "disloyalty" on the parts of employees and employers.

Some facilities aim to alter this a bit by using performance-based incentives, but this leads to a different set of problems. Very often people who are more efficient or up-code more end up with a large pay differential vs. people who don't, which leads to claims of pay discrimination, and both ways: often overhead is fixed per head, but the margin is by a percentage: someone generating 500k and gets paid 350k is more valuable than someone who generates 300k and gets paid 210k. So often people who generate 500k revenue demand that they get paid more than 350k, but if the employer does pay them more, the people get paid 210k can sue the employer, especially as people who are paid 210k are in a protected class. So the salary differential between the person who are paid 350k vs. their total income in a solo private practice is a regulatory cost that doesn't exist in a solo practice. In even larger organizations, these kinds of effects disincentivize the occurrence of people who generate 500k revenue (because they leave) and encourage uniformity in (lower) productivity. In fast-growing companies or partnerships, this effect is rescued by equity holding (i.e. total profit in excess to wages is dispersed based on ownership), but even then there is a large variability in terms of institutional culture and lots of debates as to what type of culture is more amenable to certain desirable features, how aggressive should equity play out in compensation, etc.


These are complicated issues. You can read trade publications (Modern Healthcare), or journal articles. There are conferences and academic departments devoted to these issues. With regard to specific facilities, the information is often proprietary and varies substantially based on location, and hence you can't find a "forum" for this.

This area is getting more popular--lots of interest from private equity to do "psychiatry rollover acquisition" (Google it), but it's still in its infancy. The current regulatory environment is such that large-scale rollover is unpopular, but things can change, so it's helpful to know what and how, and act defensively if necessary, etc. And basically the VERY FIRST step to learn all of this is to start your PP which forces you to learn a set of the fundamentals:
1. what is a company, how is it organized.
2. what are the regulatory steps involved in starting a physician practice that allows you to see patients.
3. what is a balance sheet, what is a P&L statement, what is a cash flow statement
4. what are the costs in starting a psychiatry practice. what is the prevailing revenue for unit economics fo service delivered by a psychiatrist?

THEN you go into the entire system with much more information which can tell you much much more about what is "fair" during job negotiations; what is a "good contract" when you act as a CMO for a payer; how do you value practice and equity, etc. etc.

 

[FlowRate]

I think I've more or less made it clear on this forum that I work for a Kaiser. It's not perfect and some day I may switch to private practice but I feel valued, our regional culture is heavily pro-MD, especially in psychiatry, we don't tolerate bad NP's and only currently have one or two on staff in other clinics (our clinic is not interested in hiring any NPs, more trouble than it's worth.) I don't feel pressured to see more patients or to provide care other than what I feel is appropriate/reasonable. So there are employed settings that are pretty good. This sort of gig won't make you mega-bucks but it's stable and I have great colleagues whose opinions I value when I want to learn from others. The biggest general downside is probably somewhat limited therapy availability but that was much worse at the academic center where I did residency. The biggest personal downside is that I can't start a cash PP on the side unless I drop to 0.5FTE and can't take on any therapy pts.

 

[dl2dp2]

I think I've more or less made it clear on this forum that I work for a Kaiser. It's not perfect and some day I may switch to private practice but I feel valued, our regional culture is heavily pro-MD, especially in psychiatry, we don't tolerate bad NP's and only currently have one or two on staff in other clinics (our clinic is not interested in hiring any NPs, more trouble than it's worth.) I don't feel pressured to see more patients or to provide care other than what I feel is appropriate/reasonable. So there are employed settings that are pretty good. This sort of gig won't make you mega-bucks but it's stable and I have great colleagues whose opinions I value when I want to learn from others.

Kaiser is not just pro-MD, my friend. Permanente Group is PHYSICIAN OWNED. You are on the partner track, if not already partnered. Kaiser is unique! You are hardly "employed" in a traditional sense.

 

[FlowRate]

Kaiser is not just pro-MD, my friend. Permanente Group is PHYSICIAN OWNED. You are on the partner track, if not already partnered. Kaiser is unique! You are hardly "employed" in a traditional sense.

Agreed overall. I don't know if this is true of all regions but here the physician group is really only in control of the physicians, the health plan controls everything else (midlevels, nurses, clinic admin staff, etc) and has quite a bit of power as the "payor" so it's not quite the same as being in a 100% physician controlled organization like some of the physician-owned hospitals.

 

[Sushirolls]

I've found bureaucracy's last motivation is to change - it's about keeping status quo and saving their a**. I'm not even going to attempt to do this at my institution because I know they'll come up with some insane reasons to get me fired, and I want to leave on my own terms. Plus, even if you do bring on change to an institution, at the end of the day you don't get to keep any of it because you are an "employee." I hope your PP is much more satisfying.

Its keeping me practicing medicine instead of quitting and becoming a rancher.

 

[justordinary]

Can you expand on details about misalignment about care delivery and lifestyle expectations?

Also, is there a website, journal, forum, or podcast...some resource that hospital administrators go to to get a sense of the current market for physicians? It would be great to read a forum similar to this, but filled with CMOs and hospital executives complaining about how to retain psychiatrists...or complaining about how weird psychiatrists are etc etc.

I think hospital executives' strategy for retaining psychiatrists is not through better treatment, compensation, and respect but through punitive measures of enforced slavery like restrictive covenant. Makes me disrespect hospital administrators even more.