Start a practice, join a practice, join a large network?

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First job out of residency

  • Starting my own

    Votes: 3 16.7%

  • Joined a practice

    Votes: 1 5.6%

  • Joined a large hospital network

    Votes: 7 38.9%

  • Other

    Votes: 7 38.9%
  • Total voters
    18
N

Notyetaphysician

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What are members on here considering after graduation? Do people want to start their own practice? If not, why not? For those that joined other practices / or even hospital networks - what went into your decision? Would you look to change?
 
I didn't want to do outpatient so I'm employed by a hospital doing inpatient and c/l. Being on your own essentially means being perpetually on call, unless you can network with other solo psychiatrists to provide call coverage for each other. That's the strongest argument against solo practice, would much rather have a group to cover call and share overhead.
 
michaelrack said:
You are not ready to start a full-time practice after graduation- get a job that allows you to start your own small private practice on the side and slowly build it.
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Why do you say this? Not disagreeing with you, just curious as to what your thought process is. Needing to build a referral network? Need for stable income in order to build a patient panel? More clinical experience?
 
nexus73 said:
I didn't want to do outpatient so I'm employed by a hospital doing inpatient and c/l. Being on your own essentially means being perpetually on call, unless you can network with other solo psychiatrists to provide call coverage for each other. That's the strongest argument against solo practice, would much rather have a group to cover call and share overhead.
Click to expand...

The flip side of this is that being on your own could be that you are NEVER on call. I never reply to non urgent messages/E-mails over the weekend or in the evening. My colleague covers me for vacation but has never needed an urgent follow-up.

If you are running a clinic, the clinic is CLOSED off business hours. Any urgent matters should be dealt with by the ER.
 
sluox said:
The flip side of this is that being on your own could be that you are NEVER on call. I never reply to non urgent messages/E-mails over the weekend or in the evening. My colleague covers me for vacation but has never needed an urgent follow-up.

If you are running a clinic, the clinic is CLOSED off business hours. Any urgent matters should be dealt with by the ER.
Click to expand...

Oh gosh, I hope you are ready for the barrage of people that will say this violates standard of care and that you could be sued if anything bad happens after hours because psychiatrists have decided they need to be available 24/7 for all patients they see.
 
sluox said:
The flip side of this is that being on your own could be that you are NEVER on call. I never reply to non urgent messages/E-mails over the weekend or in the evening. My colleague covers me for vacation but has never needed an urgent follow-up.

If you are running a clinic, the clinic is CLOSED off business hours. Any urgent matters should be dealt with by the ER.
Click to expand...
But what about urgent messages, and how do you decide what is urgent or not unless you take the call?
 
The one that pays the most, offers the best benefits, and the least amount of call.
 
nexus73 said:
But what about urgent messages, and how do you decide what is urgent or not unless you take the call?
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I don't take the call. I triage based on the transcribed voicemail. Patients know that off hours I don't call back and may not check from visit number one. People still leave messages requesting refills and what not, and new patients call and leave voicemails--will deal with it Monday morning. I don't really count that as being "on call"...do you? Do you not check your work E-mail on weekends?

On a rare occasion or two I have a borderline freaking out on me off hours, and on very rare occasions I have a patient who needs extra things on a Sunday that's sort of "urgent" (i.e. ran out/lost important meds). I do deal with this personally since this is after all cash private practice. But I know for a fact that if you work for an outpatient clinic situation you do not. This is considered extra and insurance companies do not reimburse for this. (Which is why you can charge extra "membership fee", etc. for it without running into balance billing issues if you are in-network operating in a concierge model.)

Meanwhile, when you are on CL or inpatient, your calls are assigned. If you work at a good place you get paid extra, if you don't you might not, and you might not have the option of getting out of any and your scheduling of vacations, dinners etc. have to be completely around that. I guarantee you my "non-call" off hour coverage work is much much less onerous than any of my inpatient/CL colleagues, since 1) they have to physically show up and write notes, can't be having dinner on a yacht 2) they have to round on patients they barely/don't know. I also have 100% control over when I take vacation, how long I take vacation, when and how I deal with off hour coverage, etc. Whereas the exact nature of your call duties are in general controlled by administrators.
 
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sluox said:
I don't take the call. I triage based on the transcribed voicemail. Patients know that off hours I don't call back and may not check from visit number one. People still leave messages requesting refills and what not, and new patients call and leave voicemails--will deal with it Monday morning. I don't really count that as being "on call"...do you? Do you not check your work E-mail on weekends?

On a rare occasion or two I have a borderline freaking out on me off hours, and on very rare occasions I have a patient who needs extra things on a Sunday that's sort of "urgent" (i.e. ran out/lost important meds). I do deal with this personally since this is after all cash private practice. But I know for a fact that if you work for an outpatient clinic situation you do not. This is considered extra and insurance companies do not reimburse for this. (Which is why you can charge extra "membership fee", etc. for it without running into balance billing issues if you are in-network operating in a concierge model.)

Meanwhile, when you are on CL or inpatient, your calls are assigned. If you work at a good place you get paid extra, if you don't you might not, and you might not have the option of getting out of any and your scheduling of vacations, dinners etc. have to be completely around that. I guarantee you my "non-call" off hour coverage work is much much less onerous than any of my inpatient/CL colleagues, since 1) they have to physically show up and write notes, can't be having dinner on a yacht 2) they have to round on patients they barely/don't know. I also have 100% control over when I take vacation, how long I take vacation, when and how I deal with off hour coverage, etc. Whereas the exact nature of your call duties are in general controlled by administrators.
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What about when you get a call about a suicidal patient?
 
nexus73 said:
What about when you get a call about a suicidal patient?
Click to expand...

In a clinic situation, this doesn't apply because the patient would be referred to the emergency room. No one would pick up. Have you ever tried calling CHMCs on weekends? They don't have an on call coverage service. That's the community standard.

In private practice, the case load is lower. I may have one or two per YEAR of suicidal patients calling me off hours. And since I know the patient so well I usually know what's going on. That's more DBT territory. You might have to talk the patient through for a minute or two, and if need be schedule a more urgent visit. I have also had emergency room admissions (my case load is on the sicker side), where the ER doc calls me off hours, and I deal with it on an appropriate time frame--usually in a few hours as convenient to me. I have in my few years of PP experience NEVER, EVER, EVER needed to see a patient urgently in person during off hours or on unscheduled weekend hours. (Well that's not true, I take that back, I had ONE such visits in the ER, but that was during very my early inexperience period.)
 
nexus73 said:
What about when you get a call about a suicidal patient?
Click to expand...

Is there a medical, ethical or legal difference between a suicidal patient calling their psychiatrist afterhours and a myocardial infarcted patient calling their cardiologist afterhours? They all need to hang up and call 911.

The more interesting case is a patient who calls at 2 am about a high fever and muscle stiffness after taking a new med you prescribed. I say the physician needs to call back because the patient may not be aware of a potential emergency. What if you missed the call but the patient had prior written informed consent that stated the exact symptoms for which they should consider an emergency and call 911?
 
sluox said:
In a clinic situation, this doesn't apply because the patient would be referred to the emergency room. No one would pick up. Have you ever tried calling CHMCs on weekends? They don't have an on call coverage service. That's the community standard.

In private practice, the case load is lower. I may have one or two per YEAR of suicidal patients calling me off hours. And since I know the patient so well I usually know what's going on. That's more DBT territory. You might have to talk the patient through for a minute or two, and if need be schedule a more urgent visit. I have also had emergency room admissions (my case load is on the sicker side), where the ER doc calls me off hours, and I deal with it on an appropriate time frame--usually in a few hours as convenient to me. I have in my few years of PP experience NEVER, EVER, EVER needed to see a patient urgently in person during off hours or on unscheduled weekend hours. (Well that's not true, I take that back, I had ONE such visits in the ER, but that was during very my early inexperience period.)
Click to expand...
So you are on call 24/7 just with healthy boundaries.
 
Candidate2017 said:
Is there a medical, ethical or legal difference between a suicidal patient calling their psychiatrist afterhours and a myocardial infarcted patient calling their cardiologist afterhours? They all need to hang up and call 911.

The more interesting case is a patient who calls at 2 am about a high fever and muscle stiffness after taking a new med you prescribed. I say the physician needs to call back because the patient may not be aware of a potential emergency. What if you missed the call but the patient had prior written informed consent that stated the exact symptoms for which they should consider an emergency and call 911?
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The difference is the chest pain patient wants help and guidance and will go to the ED when you tell them to, the suicidal patient might just be calling to thank you and say goodbye before killing themselves, so you might have to call the police and provide addresses and cell phone information for the suicidal patients.
 
nexus73 said:
The difference is the chest pain patient wants help and guidance and will go to the ED when you tell them to, the suicidal patient might just be calling to thank you and say goodbye before killing themselves, so you might have to call the police and provide addresses and cell phone information for the suicidal patients.
Click to expand...

Not if you from day 1 stipulate that you don't check your voicemail after hours and don't. And that's what people in CMHCs/VA clinics do.
 
NickNaylor said:
Why do you say this? Not disagreeing with you, just curious as to what your thought process is. Needing to build a referral network? Need for stable income in order to build a patient panel? More clinical experience?
Click to expand...

1. need for stable income
2. it takes a while (6-12 months) to get the billing straight. Many private insurers will require that your practice location be registered with medicare before adding their private insurance. You can't add a site as a practice location with medicare until you see your first medicare patient there.
3. you will make mistakes

my situation is a little different, in that my private practice was mainly sleep , and I could see the patients cheaply at the sleep lab I was medically director of.
A pure psychiatrist will have more expenses (rent), so don't expect to make a lot of $ off your side private practice the first year. Once you got the bugs worked out, you can rapidly expand if you wish.

Having the ability to bill will open up a lot of opportunities for you. For example, last year I picked up a side job- became medical director of a senior care unit (geriatric psych unit) with a decent stipend, but it was really good opportunity for me only because I had the capabilty of billing the patients for my services.
 
NickNaylor said:
Why do you say this? Not disagreeing with you, just curious as to what your thought process is. Needing to build a referral network? Need for stable income in order to build a patient panel? More clinical experience?
Click to expand...


I did actually start my own PP right out of residency. It is a lot of work to start and you will probably make more money the first several months with a stable job. I would suggest spending a lot of time in year 3 and year 4 learning or going to your private practice attending's offices if your serious about this. The ideal would be to get at least a part time 20 hour gig and then have your office on the side and build it. Start 1 day a week and go from there. Michael rack is dead on. I did so much homework and spent so much time before residency ended and have family in private practice yet i would say only after 4-5 months can i now say that the billing is finally smooth and this is with me investing a lot of time when the staff could not figure it out.

I will add that I love it even with the annoyances because it is something i made and built. Their is no price you can put on autonomy. Being your own boss is something I wish every doctor has the chance in some capacity to experience.
 
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TexasPhysician said:
I started a cash PP straight out of fellowship. I did work part-time elsewhere for awhile, but PP built up quickly.
Click to expand...

IIRC you're CAP-trained, though, right? I imagine that would allow a practice to build up more quickly than a general adult practice?
 
NickNaylor said:
IIRC you're CAP-trained, though, right? I imagine that would allow a practice to build up more quickly than a general adult practice?
Click to expand...

Hi. His situation is more of an exception than the normal. Location, marketing, solid reputation and perhaps being trained in the vicinity may all have played a factor in his situation but that is not a normal situation and how quickly this person built a cash PP is amazing right after fellowship.

Get a part time or 4 day week gig and try out PP 1 day a week first. Once you build it up then you can get more selective over time by not taking insurance if you decide to go that route.
 
finalpsychyear said:
Hi. His situation is more of an exception than the normal. Location, marketing, solid reputation and perhaps being trained in the vicinity may all have played a factor in his situation but that is not a normal situation and how quickly this person built a cash PP is amazing right after fellowship.

Get a part time or 4 day week gig and try out PP 1 day a week first. Once you build it up then you can get more selective over time by not taking insurance if you decide to go that route.
Click to expand...

How common is it for a medical office to rent space to a psychiatrist for 1 day a week? Maybe a surgeon could rent out his office on OR days?
 
Candidate2017 said:
How common is it for a medical office to rent space to a psychiatrist for 1 day a week? Maybe a surgeon could rent out his office on OR days?
Click to expand...

This is usually unnecessary. Commercial real estate is dirt cheap in most of the country. In expense locales there are websites like psychoffice.net for office shares.
Given psychiatrist's office usually has a set up that's similar to a lawyers or accountants office, unless you want to some other stuff (i.e. injections/TMS, etc.) you most likely will be able to lease a part time office anywhere affordably.
 
I'm planning on subleasing. Great way to start off.
 
sluox said:
I don't take the call. I triage based on the transcribed voicemail. Patients know that off hours I don't call back and may not check from visit number one. People still leave messages requesting refills and what not, and new patients call and leave voicemails--will deal with it Monday morning. I don't really count that as being "on call"...do you? Do you not check your work E-mail on weekends?

On a rare occasion or two I have a borderline freaking out on me off hours, and on very rare occasions I have a patient who needs extra things on a Sunday that's sort of "urgent" (i.e. ran out/lost important meds). I do deal with this personally since this is after all cash private practice. But I know for a fact that if you work for an outpatient clinic situation you do not. This is considered extra and insurance companies do not reimburse for this. (Which is why you can charge extra "membership fee", etc. for it without running into balance billing issues if you are in-network operating in a concierge model.)
Click to expand...

sluox said:
In a clinic situation, this doesn't apply because the patient would be referred to the emergency room. No one would pick up. Have you ever tried calling CHMCs on weekends? They don't have an on call coverage service. That's the community standard.

In private practice, the case load is lower. I may have one or two per YEAR of suicidal patients calling me off hours. And since I know the patient so well I usually know what's going on. That's more DBT territory. You might have to talk the patient through for a minute or two, and if need be schedule a more urgent visit. I have also had emergency room admissions (my case load is on the sicker side), where the ER doc calls me off hours, and I deal with it on an appropriate time frame--usually in a few hours as convenient to me. I have in my few years of PP experience NEVER, EVER, EVER needed to see a patient urgently in person during off hours or on unscheduled weekend hours. (Well that's not true, I take that back, I had ONE such visits in the ER, but that was during very my early inexperience period.)
Click to expand...

Yes! Finally someone else on here that knows what standard of care is (the definition). As long as you are discussing the parameters of treatment from day 1, either in written form (intake paperwork) or verbally, all is well. Yes, even medical-legally. Don't listen to the nay-sayers that believe that you can't start a private practice day 1. If you do your homework (contacts, location, contracts being at the top of that list) before you finish residency, you'll be fine in just a few weeks to months depending on locale. This is what I did, and all it took was a little leg work during the end of PGY3 and through PGY4.
 
sluox said:
In a clinic situation, this doesn't apply because the patient would be referred to the emergency room. No one would pick up. Have you ever tried calling CHMCs on weekends? They don't have an on call coverage service. That's the community standard.

In private practice, the case load is lower. I may have one or two per YEAR of suicidal patients calling me off hours. And since I know the patient so well I usually know what's going on. That's more DBT territory. You might have to talk the patient through for a minute or two, and if need be schedule a more urgent visit. I have also had emergency room admissions (my case load is on the sicker side), where the ER doc calls me off hours, and I deal with it on an appropriate time frame--usually in a few hours as convenient to me. I have in my few years of PP experience NEVER, EVER, EVER needed to see a patient urgently in person during off hours or on unscheduled weekend hours. (Well that's not true, I take that back, I had ONE such visits in the ER, but that was during very my early inexperience period.)
Click to expand...

What was it about your inexperience that lead you to go to the ER?
 
carlosc1dbz said:
What was it about your inexperience that lead you to go to the ER?
Click to expand...

It's a long story. The patient has a very bad personality disorder. It was my countertransference and fear of litigation that led me to visit this person on a beautiful Sunday morning. Will never do that again. Let's just leave it at that.

In general, IMHO it is inappropriate for the outpatient psychiatrist to visit borderline patients who are hospitalized or in the ER if the cause of such event is some kind of borderline crisis, since this can be reinforcing. In DBT, if the patient acts out BEFORE calling the therapist, the correct response is actually no contact for a period of time (usually a day). You want to reduce such behavior, not reinforcing them. It's kind of non-intuitive though when you start out.

I had a supervisor who reviewed this case with me later on, and it was very helpful.

Outpatient practice is challenging but not because of hours/call. That's the best part of outpatient (flexibility). The challenge of outpatient has to do with 1) marketing/business side, get paid, dealing with no shows, etc. that type of thing 2) certain clinical management issues that are not "urgent" in a strict sense, but complicated and need to be thought through, especially complicated family/treatment planning/complicated med regimen and noncompliance, etc. These issues don't come up as frequently in inpatient and CL since it's a cross-sectional type of service rather than longitudinal.

I think if you have a financial cushion you can start a practice after residency immediately and will probably be fine after 3-6 months optimistically and 6-12 months conservatively. If you take a couple of insurances you'll probably fill within 3 months.
 
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