Thinking of transitioning to private practice form a large telehealth company

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petibon25

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I'm a couple of years out of residency and looking for perspectives on a career pivot.

I'm currently working for a pretty large telehealth company that I'm sure most have seen in various social media streams. I adore most of my patients and find a sense of fulfillment from our interactions, but I'm feeling utterly burnt out. I've tried to brainstorm why this is the case, and here are a few contributing factors: 1) lack of autonomy with the patient population that I "accept" into my patient panel, 2) the oversight into my "performance" metrics (eg the inclusion of two codes being more advantageous than one but really there are just some instances when one code IS the appropriate thing to do! and 3) I am really confused as to how exactly I am getting paid based on patient interactions, and the lack of transparency here really bothers me.

Transitioning to private practice has crossed my mind as a possible outcome as I feel that it would lend to more autonomy over what my life looks like and how I provide care. I've talked with others in the field who have also suggested that operating in the world of PP would also lend to a higher hourly pay, which would translate to working less.

Is this true? I'm located in an area where I've been told that 99214 translate to ~$140-160/encounter, and we even have one insurance (that I'm in the last stages with credentialing) that will pay psychiatrists $200/hour even in the absence of medication management. But I worry that the essence of 'burn out' will not be remedied by this switch and that it is actually just the landscape of outpatient psychiatry that is draining.

Has anyone been in a similar situation and made the switch?

Really just looking for other people's experiences with working "soul challenging" outpatient corporate gigs and what it looked like for them - fulfillment wise - after transitioning to their own private practice.

thank you!

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Are you sure about those rates? That’s on the higher end for solo private practice reimbursements. Assuming 90833s are proportional, that’ll come out to around $500/hour for two 30 minute encounters. Certainly not unheard of but even in California, you’re not getting those rates unless you’ve negotiated up from the initial offer.
 
I'm 100% positive! I've asked other psychiatrists in my area and have heard the same things from both. I should preface this by saying that I live in a state where we have insurance companies that do not exist elsewhere. So the main insurance companies that we utilize are likely not utilized by other psychiatrists in the US.
 
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What state are we talking about? It isn’t Texas. Are you pleased with where you live? Is a bigger change something to consider?

There are many causes of burnout. Spending some time identifying the cause would greatly assist with determining whether this change is worthwhile.

Most of the time I love my private practice. I can choose my hours, who to terminate care with, where I work, and who is working around me. There are days when I don’t enjoy the admin aspects, firing staff, and the difficulty taking longer vacations. Sometimes I ponder doing telepsych only, buying a RV, homeschooling my kids, and traveling around the US. Maybe 1 day.

Our careers have so many options. At times, I think it is normal to wonder whether better options exist. I purposefully don’t maintain just 1 job because I enjoy the diversity, and you never know what you may enjoy more until you try it. I also think it is very important to maximize our non-career life. It is really hard to not burnout when there isn’t a strong non-work life that excites us.

Can expenses be cut? With my current set-up, I can afford to make a large stupid purchase periodically. I’m planning to get a new to me car this year, but I don’t really need one. I just want one. At some point, I plan to reduce working hours more than I already have. I wonder if I’d be happier significantly cutting hours and having a strict budget.

I’ve spoken to some psychiatrists in the USA that are unhappy with the USA and strongly considering a move to Canada. I then spoke with some Canadian psychiatrists who ended up being unhappy with Canada and strongly considering a move to another continent. We are all in various stages of the pursuit of happiness. Burn-out is real, but there are so many factors that impact our joy. A big career change may certainly be the fix, but I’d reflect on much of life to help determine whether other changes may improve it more.
 
I would suggest a middle ground. Looking into options where an employer will give you more autonomy and greater say in what you will do.

It took me some years but I have found that for the most part with my current employer. I have enough say in what I do and who I see for the pay and stability of not having to run my own business and get patients in the door.
 
What state are we talking about? It isn’t Texas. Are you pleased with where you live? Is a bigger change something to consider?

There are many causes of burnout. Spending some time identifying the cause would greatly assist with determining whether this change is worthwhile.

Most of the time I love my private practice. I can choose my hours, who to terminate care with, where I work, and who is working around me. There are days when I don’t enjoy the admin aspects, firing staff, and the difficulty taking longer vacations. Sometimes I ponder doing telepsych only, buying a RV, homeschooling my kids, and traveling around the US. Maybe 1 day.

Our careers have so many options. At times, I think it is normal to wonder whether better options exist. I purposefully don’t maintain just 1 job because I enjoy the diversity, and you never know what you may enjoy more until you try it. I also think it is very important to maximize our non-career life. It is really hard to not burnout when there isn’t a strong non-work life that excites us.

Can expenses be cut? With my current set-up, I can afford to make a large stupid purchase periodically. I’m planning to get a new to me car this year, but I don’t really need one. I just want one. At some point, I plan to reduce working hours more than I already have. I wonder if I’d be happier significantly cutting hours and having a strict budget.

I’ve spoken to some psychiatrists in the USA that are unhappy with the USA and strongly considering a move to Canada. I then spoke with some Canadian psychiatrists who ended up being unhappy with Canada and strongly considering a move to another continent. We are all in various stages of the pursuit of happiness. Burn-out is real, but there are so many factors that impact our joy. A big career change may certainly be the fix, but I’d reflect on much of life to help determine whether other changes may improve it more.
I really appreciate your response and perspective! I am pleased with where I live as most of my family network and friends live here. I think that a bigger change that is at play relates to a recent life transition that I've undergone. This has significantly impacted how I relate to my work in terms of its priority.

The level of autonomy with private practice I think is what feels high on my list. Autonomy has always been very high on my core list of values. I'm currently doing telepsych only, and in many ways I love the convenience of working from home. But then at the end of my days sometimes I'll step outside and feel like I've been so disconnected from the world all day! A hybrid set up seems ideal for me, and I think that is what I'd be able to achieve in PP. Unfortunately there really isn't much of a job market in my area aside from joining a few other clinics and a couple of other very dysfunctional hospital systems so in that way the landscape is actually quite limited.

Thank you for normalizing my wonder about other options/better options and for giving me that food for though to consider maximizing my non-career life. That is an area that could be explored for me.

As for expenses: they can be cut significantly within the next two months. I'm at the tail end of my student loans (i'm SO close!) but until that is paid off, I have a significant amount that is accounted for every month. Other than that, my family and I live quite simply.

Again thank you for your time and your thoughtful response. I really do appreciate it
 
I would suggest a middle ground. Looking into options where an employer will give you more autonomy and greater say in what you will do.

It took me some years but I have found that for the most part with my current employer. I have enough say in what I do and who I see for the pay and stability of not having to run my own business and get patients in the door.
Thank you! I did ask for more autonomy over my intakes, and this is the set up that has lended to where I am right now. There are some other things that perhaps I could ask for and I think I will explore that in the next conversation that I have with them.
 
I spent years doing general outpatient C&A psych for a large hospital system. While I generally loved it, I was working too much. I then went to a small group PP to do similar work. While this fixed many of the issues that came along with a large system, I still ended up working too much.

I see many people doing well with outpatient work in different settings (I think nearly everyone who does PP loves it), but I came to find out that I just couldn't do outpatient in a way that worked for me. So, you may find that the change in setting does it for you, but you may also find that outpatient just isn't best for you. I'm now in a residential program and love it. Like splik says above, there are other types of work as well that may click better for you.
 
I spent years doing general outpatient C&A psych for a large hospital system. While I generally loved it, I was working too much. I then went to a small group PP to do similar work. While this fixed many of the issues that came along with a large system, I still ended up working too much.

I see many people doing well with outpatient work in different settings (I think nearly everyone who does PP loves it), but I came to find out that I just couldn't do outpatient in a way that worked for me. So, you may find that the change in setting does it for you, but you may also find that outpatient just isn't best for you. I'm now in a residential program and love it. Like splik says above, there are other types of work as well that may click better for you.
Small counterpoint to the bolded, this is largely dependent on either having full or near full autonomy over how you practice OR having your own PP and not minding the admin side. I know a couple of docs who worked for local private practices who left because they got tired of 15 minute follow-ups for patients seeking benzos and stimulants (one of these places is a notorious pill mill around here) and pressure from the owners to grind more patients. I have a couple of colleagues at our academic center who took this route and another 1 or 2 I know that left PP to work outpatient at the VA.

I do agree that most outpatient docs in PP that I know do enjoy it, but the grass isn't always greener.
 
Given there are few jobs worse than these large telehealth companies, I think you will be happier whatever move you make. Private practice is not for everyone but it does offer unparalleled autonomy which for many of us beats out money. I’m in my third yr of pp and on track to exceed my compensation while employed at this point (my employed comp including benefits was around 450k). I also work far less than I used to.

I will say this is a riskier time to be transitioning into pp and people are losing their jobs (and this insurance) and cutting back on expenses etc. many people are finding it harder to recruit and retain pts. That is not to mention competing with larger companies. These tech enabled PE back companies and the proliferation of NPs in some areas.

However if it turns out outpatient isn’t for you, you might prefer inpatient, residential, IOP/PHP, corrections, utilization management etc lots of different options and they are not mutually exclusive. Outpatient isn’t all the same either. Personally i can’t think of anything worse than general adult outpatient psych but there are many different types of outpatient practice beyond that
I appreciate your perspective - I think some of the large telehealth companies do prey on unsuspecting and rather naive residents that are just about to graduate, which unfortunately was me. Yes: I do not think that the desire is financial based but that I feel having a PP could help me to build the live I want to live in terms of creating to my family ecosystem. At least that's what I'm hoping. And if it isn't, thank you so much for listing out all those different environments that psychiatrists can practice in! I really do appreciate it.
 
I spent years doing general outpatient C&A psych for a large hospital system. While I generally loved it, I was working too much. I then went to a small group PP to do similar work. While this fixed many of the issues that came along with a large system, I still ended up working too much.

I see many people doing well with outpatient work in different settings (I think nearly everyone who does PP loves it), but I came to find out that I just couldn't do outpatient in a way that worked for me. So, you may find that the change in setting does it for you, but you may also find that outpatient just isn't best for you. I'm now in a residential program and love it. Like splik says above, there are other types of work as well that may click better for you.
Thank you for sharing your experience! I've only ever talked to mentors and colleagues in PP who also really love it (for the most part), so I wanted to get a full 360 perspective on what that could look like. And like you describe your path: with turning points at different times depending on how it felt for you: I realize that that could also be what the future holds for me. Thank you again for your response.
 
Small counterpoint to the bolded, this is largely dependent on either having full or near full autonomy over how you practice OR having your own PP and not minding the admin side. I know a couple of docs who worked for local private practices who left because they got tired of 15 minute follow-ups for patients seeking benzos and stimulants (one of these places is a notorious pill mill around here) and pressure from the owners to grind more patients. I have a couple of colleagues at our academic center who took this route and another 1 or 2 I know that left PP to work outpatient at the VA.

I do agree that most outpatient docs in PP that I know do enjoy it, but the grass isn't always greener.
Yes definitely! The grass isn't always greener, and I recognize that every job will have it's "stuff" - it's just what do you want to put up with for yourself and what works best for your personality. I would get really tired of the 15 min follow-ups too! And that churn & burn is similar to what I feel currently, and I think it is a huge factor contributing to my level of job dissatisfaction.
 
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I'm back after a long time away. Had my baby in 2023 and lots of flexibility to nurse my baby which is one of the reasons I went PP. Life has changed so much and I'm getting a divorce too lol. Everyone already said what was on my mind. I'm now taking a bigger role in teaching residents. I've hit the goal of feeling like I have a good level of expertise attracting and retaining patients and wanted to try other things for variety. So now have my own practice of prescribers and psychotherapists. It's been doing reasonably well but is a full time job just managing it. And no one is giving you a stipend to do things like
-negotiate with insurance
-hire and fire people (and this happens a lot, the work force predominantly is so unmotivated--and people try to do things behind your back)
-keeping up with regulations
-I do my own billing and collections because most billing services epically suck

I've reached a point where I am satisfied with my practice and wanted to try other endeavors yet again. So teaching is where I turned, to the local residency program that I actually graduated from. There is an elective here now and I'm now in the regular didactics on teaching residents PP! It's morally refreshing. I can't emphasize enough what a nightmare HR is on a regular basis. Most people working here are fine, but there's always a train wreck situation you need to clean up. It's like wack a mole. From therapists committing insurance fraud in your business, to psychiatrists (committing medical negligence and trying to be 100% work from home but intentionally not keeping up on AIMs, high acuity cases, labs, etc. -- one such provider was bold enough to repeatedly do stuff like this, a naive young grad who thought psychiatry was so hot meaning they could do anything since how dare a family owned practice assert their boundaries?), catty front desk staff that trigger bad google reviews, etc etc. So many employees you will see could care less about the wellbeing of your practice and are only here to try to mine your practice hollow to collapse. Your employees won't understand how many hours of uncompensated back office work there is to keep a practice in good standing, beating out the competition and the marketing alone (for SEO, so patients even know you exist) is a full time job that I pay a crew of people over 30k a year to do. I digress. End of the day, I prefer this over the chaotic broken healthcare systems most work settings are entrenched in. At least you can influence how work flows, who is in the space, and I have the most work life balance here than any other option available. So what I'm saying is we all need to find the work setting that works for our personality type. @Sushirolls said it well. And hello to @splik @hamstergang @Stagg737 ! @TexasPhysician @PsyDr I missed you guys and actually being on this forum helped me so much. I started here fresh after graduation and learned so much good info here.

What now is keeping me going most is the teaching. Knowing I am helping society create hopefully better providers for themselves and their quality of life and to serve the community. It's so awesome to see their eyes get wide and venture out having better insight on how employers think, how to negotiate, where money comes from, how to optimize their pay which starts with being a good and well sought out provider in the first place. I do find in the majority of medical education, young physicians are completely clueless about PP. Actually, in all specialties and just as clueless about career advancement and how to negotiate this corporate, capitalist jungle. Especially young psychiatrists, I hate to say this but many are under the impression that after graduation we are set. We are in fact not. It's only just started. Just another chapter. The competition is fierce for the better positions. And every young psychiatrist that joined my practice behaved as if there were endless referrals (and therefore you don't have to care about your attitude or reputation) and like they were celebrities (because openings for med management were assumed to be so scarce anyways, patients would have to return to see you). But they also learned overtime that any PCP, NP, even pharmacist can dispense a script. And if you don't want to be replaced, you need to offer something that makes you harder to replace. I'm hoping (for those willing to accept the reality of the world) that being involved in the residency will better equip physicians to know what is out there, realistic compensation numbers, how to optimize their professional reputation and advance effectively to meet their goals. I hate to say this but I've met my share of young grads who were so pompous, entitled, asked for ridiculous compensation numbers at 100% work from home no less, treated nice patients at my office like they were replaceable transactions, worsened the clinic reputation, worsened clinic atmosphere with their attitudes -- all from overconfidence that they must be in so much demand that an employer would not dare call them out or *gasp* terminate the working relationship.

One of the chief residents is in an elective at my office and he's seeing a similar pattern in the more junior residents. He said the resident clinic, residents are trying to work remotely more and more. And they are opting to do remote sessions even though patients were not satisfied with this. The outcome? Less patient traffic. Actually, so bad now that the resident clinic is being evicted because they cannot pay the rent. And residents are having a hard time filling their case logs because there just aren't enough referrals coming through except the occasional benzo or stim seeker which you can only learn so much from. My colleague has residents at the VA and people are coming in underdressed and trying to go home at early times. Which, we understand the desire for work-life balance, but people need to learn to be tactful about broaching these areas. There's an effective way to approach these situations--and that certainly was not it.

We are in a very good position in society, don't get me wrong. We never have to worry about job security and will be paid far better than most Americans. But most of the psychiatry jobs in my opinion suck (if you break it down by pay per hour and all the training we had to do with loans and all). Moral of the story, letters behind your name don't grant us a lifetime of free lunch. Or any free lunch. So if the provider is ok with a crappy job, that is their life. But it is certainly possible to be a big enough pain (even as a physician) that people do not want to work with said person and good luck finding new employment because the first place a prospective employer will contact is the last employer. Physicians would benefit learning about navigating employment dynamics. As a fellow psychiatrist and physician, on graduation, we are not on the top of the food chain. But it is definitely within our reach if we are willing to put in what is necessary. We can make our dreams come true, but we gotta use the tools and our smarts. It's like graduating from a world class culinary school. The dish won't prepare itself. If someone graduated from said culinary school but opened a restaurant with crummy food, it doesn't matter, no one is coming back. Likewise, things won't be handed on graduation.

So...my longwinded digression is about, I want to help youngsters not make mistakes I have seen. Some are willing to get ahead of the curve and learn, some will want to cling on to the fantasy and will need to learn the hard way. But the faster we accept facts, deal with the reality of things, the faster we advance. The physicians I have seen the most unhappy and paid the least are precisely the ones who stayed rigid in their beliefs (which I find odd since we do therapy) and stay in denial. They resist the cognitive restructuring and being adaptable. But the most adaptable ones win!

Ok, hopefully no one hates me for this post. But it comes from a place of love. There is nothing more I wish for than to see us succeed collectively. We've worked so hard. But we need to be willing to not be in our own way and face the situation of the market for what it is. I do fantasize about helping the local residency offer something unique in the program that will perhaps increase recognition of the program--as more grads hopefully accomplish some super awesome things post graduation and move along in their careers more seamlessly. The program director expressed excitement and said I brought up an area of a knowledge gap--an area physicians could really find useful. I'm thinking of offering moonlighting opportunities here too, once I figure out how it fits with insurance billing, statutes, regulations and more. So, moonlighting here, elective, as well as didactics is where I'm headed.
 
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I'm back after a long time away. Had my baby in 2023 and lots of flexibility to nurse my baby which is one of the reasons I went PP. Life has changed so much and I'm getting a divorce too lol. Everyone already said what was on my mind. I'm now taking a bigger role in teaching residents. I've hit the goal of feeling like I have a good level of expertise attracting and retaining patients and wanted to try other things for variety. So now have my own practice of prescribers and psychotherapists. It's been doing reasonably well but is a full time job just managing it. And no one is giving you a stipend to do things like
-negotiate with insurance
-hire and fire people (and this happens a lot, the work force predominantly is so unmotivated--and people try to do things behind your back)
-keeping up with regulations
-I do my own billing and collections because most billing services epically suck

I've reached a point where I am satisfied with my practice and wanted to try other endeavors yet again. So teaching is where I turned, to the local residency program that I actually graduated from. There is an elective here now and I'm now in the regular didactics on teaching residents PP! It's morally refreshing. I can't emphasize enough what a nightmare HR is on a regular basis. Most people working here are fine, but there's always a train wreck situation you need to clean up. It's like wack a mole. From therapists committing insurance fraud in your business, to psychiatrists (committing medical negligence and trying to be 100% work from home but intentionally not keeping up on AIMs, high acuity cases, labs, etc. -- one such provider was bold enough to repeatedly do stuff like this, a naive young grad who thought psychiatry was so hot meaning they could do anything since how dare a family owned practice assert their boundaries?), catty front desk staff that trigger bad google reviews, etc etc. So many employees you will see could care less about the wellbeing of your practice and are only here to try to mine your practice hollow to collapse. Your employees won't understand how many hours of uncompensated back office work there is to keep a practice in good standing, beating out the competition and the marketing alone (for SEO, so patients even know you exist) is a full time job that I pay a crew of people over 30k a year to do. I digress. End of the day, I prefer this over the chaotic broken healthcare systems most work settings are entrenched in. At least you can influence how work flows, who is in the space, and I have the most work life balance here than any other option available. So what I'm saying is we all need to find the work setting that works for our personality type. @Sushirolls said it well. And hello to @splik @hamstergang @Stagg737 ! @TexasPhysician @PsyDr I missed you guys and actually being on this forum helped me so much. I started here fresh after graduation and learned so much good info here.

What now is keeping me going most is the teaching. Knowing I am helping society create hopefully better providers for themselves and their quality of life and to serve the community. It's so awesome to see their eyes get wide and venture out having better insight on how employers think, how to negotiate, where money comes from, how to optimize their pay which starts with being a good and well sought out provider in the first place. I do find in the majority of medical education, young physicians are completely clueless about PP. Actually, in all specialties and just as clueless about career advancement and how to negotiate this corporate, capitalist jungle. Especially young psychiatrists, I hate to say this but many are under the impression that after graduation we are set. We are in fact not. It's only just started. Just another chapter. The competition is fierce for the better positions. And every young psychiatrist that joined my practice behaved as if there were endless referrals (and therefore you don't have to care about your attitude or reputation) and like they were celebrities (because openings for med management were assumed to be so scarce anyways, patients would have to return to see you). But they also learned overtime that any PCP, NP, even pharmacist can dispense a script. And if you don't want to be replaced, you need to offer something that makes you harder to replace. I'm hoping (for those willing to accept the reality of the world) that being involved in the residency will better equip physicians to know what is out there, realistic compensation numbers, how to optimize their professional reputation and advance effectively to meet their goals. I hate to say this but I've met my share of young grads who were so pompous, entitled, asked for ridiculous compensation numbers at 100% work from home no less, treated nice patients at my office like they were replaceable transactions, worsened the clinic reputation, worsened clinic atmosphere with their attitudes -- all from overconfidence that they must be in so much demand that an employer would not dare call them out or *gasp* terminate the working relationship.

One of the chief residents is in an elective at my office and he's seeing a similar pattern in the more junior residents. He said the resident clinic, residents are trying to work remotely more and more. And they are opting to do remote sessions even though patients were not satisfied with this. The outcome? Less patient traffic. Actually, so bad now that the resident clinic is being evicted because they cannot pay the rent. And residents are having a hard time filling their case logs because there just aren't enough referrals coming through except the occasional benzo or stim seeker which you can only learn so much from. My colleague has residents at the VA and people are coming in underdressed and trying to go home at early times. Which, we understand the desire for work-life balance, but people need to learn to be tactful about broaching these areas. There's an effective way to approach these situations--and that certainly was not it.

We are in a very good position in society, don't get me wrong. We never have to worry about job security and will be paid far better than most Americans. But most of the psychiatry jobs in my opinion suck (if you break it down by pay per hour and all the training we had to do with loans and all). Moral of the story, letters behind your name don't grant us a lifetime of free lunch. Or any free lunch. So if the provider is ok with a crappy job, that is their life. But it is certainly possible to be a big enough pain (even as a physician) that people do not want to work with said person and good luck finding new employment because the first place a prospective employer will contact is the last employer. Physicians would benefit learning about navigating employment dynamics. As a fellow psychiatrist and physician, on graduation, we are not on the top of the food chain. But it is definitely within our reach if we are willing to put in what is necessary. We can make our dreams come true, but we gotta use the tools and our smarts. It's like graduating from a world class culinary school. The dish won't prepare itself. If someone graduated from said culinary school but opened a restaurant with crummy food, it doesn't matter, no one is coming back. Likewise, things won't be handed on graduation.

So...my longwinded digression is about, I want to help youngsters not make mistakes I have seen. Some are willing to get ahead of the curve and learn, some will want to cling on to the fantasy and will need to learn the hard way. But the faster we accept facts, deal with the reality of things, the faster we advance. The physicians I have seen the most unhappy and paid the least are precisely the ones who stayed rigid in their beliefs (which I find odd since we do therapy) and stay in denial. They resist the cognitive restructuring and being adaptable. But the most adaptable ones win!

Ok, hopefully no one hates me for this post. But it comes from a place of love. There is nothing more I wish for than to see us succeed collectively. We've worked so hard. But we need to be willing to not be in our own way and face the situation of the market for what it is. I do fantasize about helping the local residency offer something unique in the program that will perhaps increase recognition of the program--as more grads hopefully accomplish some super awesome things post graduation and move along in their careers more seamlessly. The program director expressed excitement and said I brought up an area of a knowledge gap--an area physicians could really find useful. I'm thinking of offering moonlighting opportunities here too, once I figure out how it fits with insurance billing, statutes, regulations and more. So, moonlighting here, elective, as well as didactics is where I'm headed.

What a fantastic post. This was something I wish I read when I was in residency. It’s not always bed of roses running your own practice. Dealing with people in any capacity, whether for work or platonic or romantic, is a double edge sword.

Would you share the outcome of your divorce? As a physician, how much financial damage did divorce do you? Did you do anything to mitigate the financial damage?
 
@randomdoc1
High value post right there. So true.
I've avoided going big and expanding to bring on therapists, or any really because of that constant HR issue. I've been very fortunate with one good quality assistant and not needed to churn the HR wheel. But yeah, competition is real.
 
PP has kept me in Psychiatry.
Otherwise I would have been in danger of leaving medicine altogether.
Things are still a pain, but it's a lower cesspool to wade thru. Up to hips and not chest deep. And when it rains get less up splash.
Thanks for your reply!! Ive been looking through all your posts on putting together a PP - it's been so helpful with this journey, and i'm really grateful for your graciousness with these resources!
 
I'm back after a long time away. Had my baby in 2023 and lots of flexibility to nurse my baby which is one of the reasons I went PP. Life has changed so much and I'm getting a divorce too lol. Everyone already said what was on my mind. I'm now taking a bigger role in teaching residents. I've hit the goal of feeling like I have a good level of expertise attracting and retaining patients and wanted to try other things for variety. So now have my own practice of prescribers and psychotherapists. It's been doing reasonably well but is a full time job just managing it. And no one is giving you a stipend to do things like
-negotiate with insurance
-hire and fire people (and this happens a lot, the work force predominantly is so unmotivated--and people try to do things behind your back)
-keeping up with regulations
-I do my own billing and collections because most billing services epically suck

I've reached a point where I am satisfied with my practice and wanted to try other endeavors yet again. So teaching is where I turned, to the local residency program that I actually graduated from. There is an elective here now and I'm now in the regular didactics on teaching residents PP! It's morally refreshing. I can't emphasize enough what a nightmare HR is on a regular basis. Most people working here are fine, but there's always a train wreck situation you need to clean up. It's like wack a mole. From therapists committing insurance fraud in your business, to psychiatrists (committing medical negligence and trying to be 100% work from home but intentionally not keeping up on AIMs, high acuity cases, labs, etc. -- one such provider was bold enough to repeatedly do stuff like this, a naive young grad who thought psychiatry was so hot meaning they could do anything since how dare a family owned practice assert their boundaries?), catty front desk staff that trigger bad google reviews, etc etc. So many employees you will see could care less about the wellbeing of your practice and are only here to try to mine your practice hollow to collapse. Your employees won't understand how many hours of uncompensated back office work there is to keep a practice in good standing, beating out the competition and the marketing alone (for SEO, so patients even know you exist) is a full time job that I pay a crew of people over 30k a year to do. I digress. End of the day, I prefer this over the chaotic broken healthcare systems most work settings are entrenched in. At least you can influence how work flows, who is in the space, and I have the most work life balance here than any other option available. So what I'm saying is we all need to find the work setting that works for our personality type. @Sushirolls said it well. And hello to @splik @hamstergang @Stagg737 ! @TexasPhysician @PsyDr I missed you guys and actually being on this forum helped me so much. I started here fresh after graduation and learned so much good info here.

What now is keeping me going most is the teaching. Knowing I am helping society create hopefully better providers for themselves and their quality of life and to serve the community. It's so awesome to see their eyes get wide and venture out having better insight on how employers think, how to negotiate, where money comes from, how to optimize their pay which starts with being a good and well sought out provider in the first place. I do find in the majority of medical education, young physicians are completely clueless about PP. Actually, in all specialties and just as clueless about career advancement and how to negotiate this corporate, capitalist jungle. Especially young psychiatrists, I hate to say this but many are under the impression that after graduation we are set. We are in fact not. It's only just started. Just another chapter. The competition is fierce for the better positions. And every young psychiatrist that joined my practice behaved as if there were endless referrals (and therefore you don't have to care about your attitude or reputation) and like they were celebrities (because openings for med management were assumed to be so scarce anyways, patients would have to return to see you). But they also learned overtime that any PCP, NP, even pharmacist can dispense a script. And if you don't want to be replaced, you need to offer something that makes you harder to replace. I'm hoping (for those willing to accept the reality of the world) that being involved in the residency will better equip physicians to know what is out there, realistic compensation numbers, how to optimize their professional reputation and advance effectively to meet their goals. I hate to say this but I've met my share of young grads who were so pompous, entitled, asked for ridiculous compensation numbers at 100% work from home no less, treated nice patients at my office like they were replaceable transactions, worsened the clinic reputation, worsened clinic atmosphere with their attitudes -- all from overconfidence that they must be in so much demand that an employer would not dare call them out or *gasp* terminate the working relationship.

One of the chief residents is in an elective at my office and he's seeing a similar pattern in the more junior residents. He said the resident clinic, residents are trying to work remotely more and more. And they are opting to do remote sessions even though patients were not satisfied with this. The outcome? Less patient traffic. Actually, so bad now that the resident clinic is being evicted because they cannot pay the rent. And residents are having a hard time filling their case logs because there just aren't enough referrals coming through except the occasional benzo or stim seeker which you can only learn so much from. My colleague has residents at the VA and people are coming in underdressed and trying to go home at early times. Which, we understand the desire for work-life balance, but people need to learn to be tactful about broaching these areas. There's an effective way to approach these situations--and that certainly was not it.

We are in a very good position in society, don't get me wrong. We never have to worry about job security and will be paid far better than most Americans. But most of the psychiatry jobs in my opinion suck (if you break it down by pay per hour and all the training we had to do with loans and all). Moral of the story, letters behind your name don't grant us a lifetime of free lunch. Or any free lunch. So if the provider is ok with a crappy job, that is their life. But it is certainly possible to be a big enough pain (even as a physician) that people do not want to work with said person and good luck finding new employment because the first place a prospective employer will contact is the last employer. Physicians would benefit learning about navigating employment dynamics. As a fellow psychiatrist and physician, on graduation, we are not on the top of the food chain. But it is definitely within our reach if we are willing to put in what is necessary. We can make our dreams come true, but we gotta use the tools and our smarts. It's like graduating from a world class culinary school. The dish won't prepare itself. If someone graduated from said culinary school but opened a restaurant with crummy food, it doesn't matter, no one is coming back. Likewise, things won't be handed on graduation.

So...my longwinded digression is about, I want to help youngsters not make mistakes I have seen. Some are willing to get ahead of the curve and learn, some will want to cling on to the fantasy and will need to learn the hard way. But the faster we accept facts, deal with the reality of things, the faster we advance. The physicians I have seen the most unhappy and paid the least are precisely the ones who stayed rigid in their beliefs (which I find odd since we do therapy) and stay in denial. They resist the cognitive restructuring and being adaptable. But the most adaptable ones win!

Ok, hopefully no one hates me for this post. But it comes from a place of love. There is nothing more I wish for than to see us succeed collectively. We've worked so hard. But we need to be willing to not be in our own way and face the situation of the market for what it is. I do fantasize about helping the local residency offer something unique in the program that will perhaps increase recognition of the program--as more grads hopefully accomplish some super awesome things post graduation and move along in their careers more seamlessly. The program director expressed excitement and said I brought up an area of a knowledge gap--an area physicians could really find useful. I'm thinking of offering moonlighting opportunities here too, once I figure out how it fits with insurance billing, statutes, regulations and more. So, moonlighting here, elective, as well as didactics is where I'm headed.
I really appreciate all of your thoughts and perspectives and funny enough (even though I am relatively fresh out of residency) - I can relate to change in work ethic and professionalism in the younger years (I saw it a lot in the younger residents as I was phasing out and as I return to my previous residency program to work, it is palpable with the residents that I work with). The satisfying nature of teaching is also something that I identify with!! This is something that I'm trying to explore more on a part-time basis. I love your statement "end of the day, I prefer this over the chaotic broken healthcare system" because I think what gets at me the most is when I'm pushed to do things that are at ends with what I feel is good medicine. So thank you again for your time in crafting your response. I appreciate it!
 
What a fantastic post. This was something I wish I read when I was in residency. It’s not always bed of roses running your own practice. Dealing with people in any capacity, whether for work or platonic or romantic, is a double edge sword.

Would you share the outcome of your divorce? As a physician, how much financial damage did divorce do you? Did you do anything to mitigate the financial damage?
I reside I think in what we call a common law marriage state. Everything is just split 50/50. And then things like child support, childcare, that is specified in the marital settle agreement. They look at the incomes of both spouses. Then they decide if spouses will have the kids 50/50. If incomes are equal and 50/50, no child support to be paid. And child expenses are split 50/50. We use an app to track expenses and it works perfectly. You upload receipts and can pay directly in the app. The app also has software for you to split up child time. We decided to live on the same block so the kids can literally just walk freely between the households. Our incomes are comparable, so everything got split 50/50. My practice is projected to grow rather rapidly and earning potential likewise. So it was in my best interest to get out faster before my projected income rises and he gets a bigger share (e.g. child expense breaks).

I do think it was unfair that my practice was given a fair market value of over a million dollars (although care directly rendered or billed under me makes over 65% of the clinic revenue--it's not like I can sell my skills off). And that was included in the assets to be split. Fair market value does not necessarily mean that is what you can sell the practice for. But that's just how the law is written--unfair as it is. Felt like I paid him some sort of alimony in advance although he's perfectly capable of working. Attorney fees are super expensive. We just used a mediator to save cost for both of us. Nothing stood out to me in a way I felt that securing my own counsel would have given me a more favorable outcome. I do suspect he hid some finances away, but the longer we stay in the mediation process, my net worth will only increase and I'd have to owe more for not even a guaranteed better outcome. So cut the tie fast and nothing has to be split anymore.

I'm teaching my kids based on my own experience. I don't see a value in being legally married. 50% end up in divorce and the finances get so messy. Be married in spirit and keep your finances clean. I made the fatal mistake of not being financially literate, investing, and knowing exactly what we have from the start. That would have helped ensure minimal losses down the road. Things can really suck on divorce. I mean, if you have a stay at home parent and you divorce, you're screwed with maintenance. Or get a prenup? But I have no idea how those work.

I really appreciate all of your thoughts and perspectives and funny enough (even though I am relatively fresh out of residency) - I can relate to change in work ethic and professionalism in the younger years (I saw it a lot in the younger residents as I was phasing out and as I return to my previous residency program to work, it is palpable with the residents that I work with). The satisfying nature of teaching is also something that I identify with!! This is something that I'm trying to explore more on a part-time basis. I love your statement "end of the day, I prefer this over the chaotic broken healthcare system" because I think what gets at me the most is when I'm pushed to do things that are at ends with what I feel is good medicine. So thank you again for your time in crafting your response. I appreciate it!
Yes, I'm so happy to see your perspective. We go from student, to resident, to young physician to a more seasoned one. We all go through it. It's interesting to see the situation in all these lenses and then add the lens of employed physician to employer of physicians. Hoping to help motivate more physicians. The only way to a better life is to contribute our part to society and set healthy boundaries as well. So it starts with doing good : ).
 
There are significant benefits to marriage legally, financially (for non-dual MD households) and emotionally. Heck, there are health benefits. There are also significant benefits to prenups that rise to astronomic levels when a private practice is involved. Fortunately, you don't need to know how prenups work before getting married, that's what attorneys are paid for, albeit only a tiny fraction of what they are in a divorce without a prenup. You only need to know that prenups are a necessary preparatory part of getting married. I also think the poster above meant a community property state. If they lived in a common law marriage state (of which there are only a handful), it wouldn't really matter if they had taken the effort to get the piece of paper.
 
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I'm back after a long time away. Had my baby in 2023 and lots of flexibility to nurse my baby which is one of the reasons I went PP. Life has changed so much and I'm getting a divorce too lol. Everyone already said what was on my mind. I'm now taking a bigger role in teaching residents. I've hit the goal of feeling like I have a good level of expertise attracting and retaining patients and wanted to try other things for variety. So now have my own practice of prescribers and psychotherapists. It's been doing reasonably well but is a full time job just managing it. And no one is giving you a stipend to do things like
-negotiate with insurance
-hire and fire people (and this happens a lot, the work force predominantly is so unmotivated--and people try to do things behind your back)
-keeping up with regulations
-I do my own billing and collections because most billing services epically suck

I've reached a point where I am satisfied with my practice and wanted to try other endeavors yet again. So teaching is where I turned, to the local residency program that I actually graduated from. There is an elective here now and I'm now in the regular didactics on teaching residents PP! It's morally refreshing. I can't emphasize enough what a nightmare HR is on a regular basis. Most people working here are fine, but there's always a train wreck situation you need to clean up. It's like wack a mole. From therapists committing insurance fraud in your business, to psychiatrists (committing medical negligence and trying to be 100% work from home but intentionally not keeping up on AIMs, high acuity cases, labs, etc. -- one such provider was bold enough to repeatedly do stuff like this, a naive young grad who thought psychiatry was so hot meaning they could do anything since how dare a family owned practice assert their boundaries?), catty front desk staff that trigger bad google reviews, etc etc. So many employees you will see could care less about the wellbeing of your practice and are only here to try to mine your practice hollow to collapse. Your employees won't understand how many hours of uncompensated back office work there is to keep a practice in good standing, beating out the competition and the marketing alone (for SEO, so patients even know you exist) is a full time job that I pay a crew of people over 30k a year to do. I digress. End of the day, I prefer this over the chaotic broken healthcare systems most work settings are entrenched in. At least you can influence how work flows, who is in the space, and I have the most work life balance here than any other option available. So what I'm saying is we all need to find the work setting that works for our personality type. @Sushirolls said it well. And hello to @splik @hamstergang @Stagg737 ! @TexasPhysician @PsyDr I missed you guys and actually being on this forum helped me so much. I started here fresh after graduation and learned so much good info here.

What now is keeping me going most is the teaching. Knowing I am helping society create hopefully better providers for themselves and their quality of life and to serve the community. It's so awesome to see their eyes get wide and venture out having better insight on how employers think, how to negotiate, where money comes from, how to optimize their pay which starts with being a good and well sought out provider in the first place. I do find in the majority of medical education, young physicians are completely clueless about PP. Actually, in all specialties and just as clueless about career advancement and how to negotiate this corporate, capitalist jungle. Especially young psychiatrists, I hate to say this but many are under the impression that after graduation we are set. We are in fact not. It's only just started. Just another chapter. The competition is fierce for the better positions. And every young psychiatrist that joined my practice behaved as if there were endless referrals (and therefore you don't have to care about your attitude or reputation) and like they were celebrities (because openings for med management were assumed to be so scarce anyways, patients would have to return to see you). But they also learned overtime that any PCP, NP, even pharmacist can dispense a script. And if you don't want to be replaced, you need to offer something that makes you harder to replace. I'm hoping (for those willing to accept the reality of the world) that being involved in the residency will better equip physicians to know what is out there, realistic compensation numbers, how to optimize their professional reputation and advance effectively to meet their goals. I hate to say this but I've met my share of young grads who were so pompous, entitled, asked for ridiculous compensation numbers at 100% work from home no less, treated nice patients at my office like they were replaceable transactions, worsened the clinic reputation, worsened clinic atmosphere with their attitudes -- all from overconfidence that they must be in so much demand that an employer would not dare call them out or *gasp* terminate the working relationship.

One of the chief residents is in an elective at my office and he's seeing a similar pattern in the more junior residents. He said the resident clinic, residents are trying to work remotely more and more. And they are opting to do remote sessions even though patients were not satisfied with this. The outcome? Less patient traffic. Actually, so bad now that the resident clinic is being evicted because they cannot pay the rent. And residents are having a hard time filling their case logs because there just aren't enough referrals coming through except the occasional benzo or stim seeker which you can only learn so much from. My colleague has residents at the VA and people are coming in underdressed and trying to go home at early times. Which, we understand the desire for work-life balance, but people need to learn to be tactful about broaching these areas. There's an effective way to approach these situations--and that certainly was not it.

We are in a very good position in society, don't get me wrong. We never have to worry about job security and will be paid far better than most Americans. But most of the psychiatry jobs in my opinion suck (if you break it down by pay per hour and all the training we had to do with loans and all). Moral of the story, letters behind your name don't grant us a lifetime of free lunch. Or any free lunch. So if the provider is ok with a crappy job, that is their life. But it is certainly possible to be a big enough pain (even as a physician) that people do not want to work with said person and good luck finding new employment because the first place a prospective employer will contact is the last employer. Physicians would benefit learning about navigating employment dynamics. As a fellow psychiatrist and physician, on graduation, we are not on the top of the food chain. But it is definitely within our reach if we are willing to put in what is necessary. We can make our dreams come true, but we gotta use the tools and our smarts. It's like graduating from a world class culinary school. The dish won't prepare itself. If someone graduated from said culinary school but opened a restaurant with crummy food, it doesn't matter, no one is coming back. Likewise, things won't be handed on graduation.

So...my longwinded digression is about, I want to help youngsters not make mistakes I have seen. Some are willing to get ahead of the curve and learn, some will want to cling on to the fantasy and will need to learn the hard way. But the faster we accept facts, deal with the reality of things, the faster we advance. The physicians I have seen the most unhappy and paid the least are precisely the ones who stayed rigid in their beliefs (which I find odd since we do therapy) and stay in denial. They resist the cognitive restructuring and being adaptable. But the most adaptable ones win!

Ok, hopefully no one hates me for this post. But it comes from a place of love. There is nothing more I wish for than to see us succeed collectively. We've worked so hard. But we need to be willing to not be in our own way and face the situation of the market for what it is. I do fantasize about helping the local residency offer something unique in the program that will perhaps increase recognition of the program--as more grads hopefully accomplish some super awesome things post graduation and move along in their careers more seamlessly. The program director expressed excitement and said I brought up an area of a knowledge gap--an area physicians could really find useful. I'm thinking of offering moonlighting opportunities here too, once I figure out how it fits with insurance billing, statutes, regulations and more. So, moonlighting here, elective, as well as didactics is where I'm headed.
Sorry you have to deal with the divorce, but welcome back! Always enjoyed your input and the directness of your advice that your avatar so fittingly depicts 🤣
 
I spent years doing general outpatient C&A psych for a large hospital system. While I generally loved it, I was working too much. I then went to a small group PP to do similar work. While this fixed many of the issues that came along with a large system, I still ended up working too much.

I see many people doing well with outpatient work in different settings (I think nearly everyone who does PP loves it), but I came to find out that I just couldn't do outpatient in a way that worked for me. So, you may find that the change in setting does it for you, but you may also find that outpatient just isn't best for you. I'm now in a residential program and love it. Like splik says above, there are other types of work as well that may click better for you.
Can you tell me about residential work? I’ve been interested in this for myself but have no experience with it.
 
I reside I think in what we call a common law marriage state. Everything is just split 50/50. And then things like child support, childcare, that is specified in the marital settle agreement. They look at the incomes of both spouses. Then they decide if spouses will have the kids 50/50. If incomes are equal and 50/50, no child support to be paid. And child expenses are split 50/50. We use an app to track expenses and it works perfectly. You upload receipts and can pay directly in the app. The app also has software for you to split up child time. We decided to live on the same block so the kids can literally just walk freely between the households. Our incomes are comparable, so everything got split 50/50. My practice is projected to grow rather rapidly and earning potential likewise. So it was in my best interest to get out faster before my projected income rises and he gets a bigger share (e.g. child expense breaks).

I do think it was unfair that my practice was given a fair market value of over a million dollars (although care directly rendered or billed under me makes over 65% of the clinic revenue--it's not like I can sell my skills off). And that was included in the assets to be split. Fair market value does not necessarily mean that is what you can sell the practice for. But that's just how the law is written--unfair as it is. Felt like I paid him some sort of alimony in advance although he's perfectly capable of working. Attorney fees are super expensive. We just used a mediator to save cost for both of us. Nothing stood out to me in a way I felt that securing my own counsel would have given me a more favorable outcome. I do suspect he hid some finances away, but the longer we stay in the mediation process, my net worth will only increase and I'd have to owe more for not even a guaranteed better outcome. So cut the tie fast and nothing has to be split anymore.

I'm teaching my kids based on my own experience. I don't see a value in being legally married. 50% end up in divorce and the finances get so messy. Be married in spirit and keep your finances clean. I made the fatal mistake of not being financially literate, investing, and knowing exactly what we have from the start. That would have helped ensure minimal losses down the road. Things can really suck on divorce. I mean, if you have a stay at home parent and you divorce, you're screwed with maintenance. Or get a prenup? But I have no idea how those work.

Thanks for sharing the details. It sounds like the higher-earning or wealthier partner gets the short end of the stick in divorces, especially without prenups. I'm not sure if I want kids, but if I do in the future, I'm considering surrogacy and hiring whatever help is needed to raise them. If I get married, a prenup is a must. The last person I was seriously talking to, I told her I was vetting her over several years, and if marriage happened, there would definitely be a prenup due to the vast discrepancy in wealth. She didn’t last three months.

How did they value your practice? Was it a multiple of revenue or profits? I can’t imagine it would be valued by assets since psychiatry private practices are not capital intensive.

A lot of us progressed through our careers in parallel over the years, linked by this forum. It's interesting to see how our lives played out.
 
I really appreciate all of your thoughts and perspectives and funny enough (even though I am relatively fresh out of residency) - I can relate to change in work ethic and professionalism in the younger years (I saw it a lot in the younger residents as I was phasing out and as I return to my previous residency program to work, it is palpable with the residents that I work with). The satisfying nature of teaching is also something that I identify with!! This is something that I'm trying to explore more on a part-time basis. I love your statement "end of the day, I prefer this over the chaotic broken healthcare system" because I think what gets at me the most is when I'm pushed to do things that are at ends with what I feel is good medicine. So thank you again for your time in crafting your response. I appreciate it!
Work ethic/professionalism issues are very real. There's a large, well-known academic center near me and I've been blown away by the abysmal lack of professionalism when interacting with trainees there. I've had patients transfer care from there, as well as transfer care to there, as well as patients I've done one-time consultations for when their subspecialty clinic is full. I can count on the fingers of one hand how many times a resident has responded to my attempt to reach out to them to discuss the patient. Actually, I can count on the finger (singular) of one hand, and that resident's supervisor was my APD during fellowship who told her to expect me to reach out to discuss the patient. I had one, very complicated patient, that I wrote a long note about and sent a concise summary via Epic message to the resident. Radio silence, not even an acknowledgement that the message had been received. It had been received though because the patient ended up deciding that they wanted to continue with me (originally was a one time consultation) and said the resident had mentioned getting my message. And yup, it was documented in the next note that I had "reached out". Like come on, not even a brief one line response acknowledging you got my message or note?
 
@petibon25

My first job after residency was dissatisfying. I had a lot of the same complaints you did. I didn’t have much autonomy regarding which patients I accepted, and I didn’t know how my pay was determined. I was under a production model, but I never received any numbers to justify the amount I got in my checking account. My biggest complaint was that I was getting hosed financially. I didn’t trust the owner to be honest, so I left after less than a year.

Since then, I’ve been doing much better financially. I work for a hospital system doing inpatient, outpatient, consults, and ECT. I would do more IV ketamine as well, but insurance companies don’t want to cover those, so most of the ketamine I prescribe is Spravato. I’ve become a much better clinician since making this change.

I spoke with a good friend who asked if I wanted to start my own private practice. I told him I didn’t. First, I don’t think I would be more financially successful running my own practice. There’s definitely an economy of scale advantage when it comes to negotiating good rates with insurance companies. Second, I would be responsible for running the business and wouldn’t necessarily be paid for that extra work. Third, as @randomdoc1 pointed out, managing people is tough. Also, knowing that the practice would be responsible for the livelihoods of several people would make it harder to walk away. If I built something, due to the cognitive bias of it being my “baby,” it would be hard to leave. It’s possible I’ll walk away from clinical medicine in 10 years or less -- not because I dislike the work, but because I want to see what else life has to offer beyond work. I'm thinking of exploring different countries and meeting different people while living in luxury.

A lot of finding the best fit in psychiatry involves trial and error, so keep experimenting if you’re not satisfied.
 
I'm teaching my kids based on my own experience. I don't see a value in being legally married. 50% end up in divorce and the finances get so messy. Be married in spirit and keep your finances clean. I made the fatal mistake of not being financially literate, investing, and knowing exactly what we have from the start. That would have helped ensure minimal losses down the road. Things can really suck on divorce. I mean, if you have a stay at home parent and you divorce, you're screwed with maintenance. Or get a prenup? But I have no idea how those work.
Welcome back!

I will gently push back and note that building something (even a Vanguard account) with someone else is more pleasurable and easier than doing it alone. I think there is a lot of hindsight bias after things go poorly. I know a few colleagues who have been through divorce but all my friends who have MDs are still on their initial marriage (as the data suggests is relatively likely, especially as several of them are dual MD households). There is also messiness to sharing expenses with someone that you live with and have children with. I get to pay for everything (as a male it's just nice), we have only a few accounts to keep track of, and day-to-day just lacks any friction or worrying about money. Divorce is always going to suck and making it suck a bit more with regular joint finances certainly has a -EV, however the 75%+ of physician marriages that work out get a +EV from having joint finances. Everyone just needs to maximize their own EV.
 
I reside I think in what we call a common law marriage state. Everything is just split 50/50. And then things like child support, childcare, that is specified in the marital settle agreement. They look at the incomes of both spouses. Then they decide if spouses will have the kids 50/50. If incomes are equal and 50/50, no child support to be paid. And child expenses are split 50/50. We use an app to track expenses and it works perfectly. You upload receipts and can pay directly in the app. The app also has software for you to split up child time. We decided to live on the same block so the kids can literally just walk freely between the households. Our incomes are comparable, so everything got split 50/50. My practice is projected to grow rather rapidly and earning potential likewise. So it was in my best interest to get out faster before my projected income rises and he gets a bigger share (e.g. child expense breaks).

I do think it was unfair that my practice was given a fair market value of over a million dollars (although care directly rendered or billed under me makes over 65% of the clinic revenue--it's not like I can sell my skills off). And that was included in the assets to be split. Fair market value does not necessarily mean that is what you can sell the practice for. But that's just how the law is written--unfair as it is. Felt like I paid him some sort of alimony in advance although he's perfectly capable of working. Attorney fees are super expensive. We just used a mediator to save cost for both of us. Nothing stood out to me in a way I felt that securing my own counsel would have given me a more favorable outcome. I do suspect he hid some finances away, but the longer we stay in the mediation process, my net worth will only increase and I'd have to owe more for not even a guaranteed better outcome. So cut the tie fast and nothing has to be split anymore.

I'm teaching my kids based on my own experience. I don't see a value in being legally married. 50% end up in divorce and the finances get so messy. Be married in spirit and keep your finances clean. I made the fatal mistake of not being financially literate, investing, and knowing exactly what we have from the start. That would have helped ensure minimal losses down the road. Things can really suck on divorce. I mean, if you have a stay at home parent and you divorce, you're screwed with maintenance. Or get a prenup? But I have no idea how those work.


Yes, I'm so happy to see your perspective. We go from student, to resident, to young physician to a more seasoned one. We all go through it. It's interesting to see the situation in all these lenses and then add the lens of employed physician to employer of physicians. Hoping to help motivate more physicians. The only way to a better life is to contribute our part to society and set healthy boundaries as well. So it starts with doing good : ).

Thanks for all your posts over the years. Can you go into what led to the divorce?
 
1) @AD04

a. A business is usually valued at around 3X EBITDA. If you have other psychiatrists, that X might go higher. If you have only you, or opened up last year, that X might go lower.

b. You can protect your money through a prenup. However there there are many ways to void a prenup, and some states allow prenups to expire. Alternatives include putting your assets into an irrevocable trust, an LLC, or an FLP prior to marriage. With the right lawyers, an actual LLC can offer a LOT of liability protection in the event of litigation/divorce. It might seem strange, but ask your surgical colleagues about how their surgical practice is set up, and how they pay themselves. They will know exactly what I am talking about, and probably have a reference for you.

2) @randomdoc1

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There are definitely ways for a spouse to convince a judge to void a prenup (and then you sue your original attorney for malpractice), but I almost never hear about that in actual practice. Instead, I hear complaints like the poster above who didn't even consider a prenup. No arguments from me about LLCs, I'm sure they are great and necessary for private practices, but you want the prenup too or you will definitely still be on the hook for significant spousal support, potentially indefinitely. In terms of sunset clauses, they can definitely be included as part of the prenup (not that I would recommend that), but I'm not sure if there any states that have them automatically generate without being formally written down. I can't find any. I know Maine had them expire when a child was born or adopted, but they fortunately ended that in 1993.
 
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I'm laughing at how this thread evolved into discussing divorce and the financial risks! LOL. 🤣But the damage is REAL. Get a prenup even if you do not see a need for one. I married in my early 20s and always thought I'd work as a part time physician under an employer and be half housewife. So at that time, his net worth was far higher and the discrepancy was assumed to not change. I never imagined I'd end up at this place in my career (it started with an innocent opening of a small office space and it just exploded--be careful what you wish for I guess) and BAM, I get screwed in the divorce settlement. hahahaha

Hey, in my didactics, maybe I should include...get a prenup so your PP doesn't get gobbled up LOL
 
I'm laughing at how this thread evolved into discussing divorce and the financial risks! LOL. 🤣But the damage is REAL. Get a prenup even if you do not see a need for one. I married in my early 20s and always thought I'd work as a part time physician under an employer and be half housewife. So at that time, his net worth was far higher and the discrepancy was assumed to not change. I never imagined I'd end up at this place in my career (it started with an innocent opening of a small office space and it just exploded--be careful what you wish for I guess) and BAM, I get screwed in the divorce settlement. hahahaha

Hey, in my didactics, maybe I should include...get a prenup so your PP doesn't get gobbled up LOL

How timely haha

 
No arguments from me about LLCs, I'm sure they are great and necessary for private practices, but you want the prenup too or you will definitely still be on the hook for significant spousal support, potentially indefinitely. In terms of sunset clauses, they can definitely be included as part of the prenup (not that I would recommend that), but I'm not sure if there any states that have them automatically generate without being formally written down.

LLCs aren't protected from divorce. They tend to be a little more complicated tax-wise, and lead to more willingness to negotiate. And spousal support is no longer indefinite in any state.

In general, pre-nups don't guarantee an ex won't take half the marital assets, as pre-nups must be "fair". If you have $200k in assets, good luck getting a court to enforce a pre-nup that says your spouse of 5+ years is limited to 10% of your assets. They are definitely getting 50%. If you are worth $10 million, then that 10% clause might be ruled "fair" by the divorce court.

Pre-nups are most useful to split specific assets. For example, you specify you get to keep your $5 million horse farm upon marriage dissolution, but you pay your ex 40% of its value (of course "value" can be another legal fight). For the married med students and residents, keep in mind your medical license is considered an asset to be divided, which is a lot more vague/unfair than dividing an actual practice with actual value.

If I get married, a prenup is a must. The last person I was seriously talking to, I told her I was vetting her over several years, and if marriage happened, there would definitely be a prenup due to the vast discrepancy in wealth. She didn’t last three months.

In the end, marriage is always a legal contract. She is basically like hospital HR: she wanted you to sign the standard contract with zero changes, but you wanted a negotiated contract.
 
LLCs aren't protected from divorce. They tend to be a little more complicated tax-wise, and lead to more willingness to negotiate. And spousal support is no longer indefinite in any state.

In general, pre-nups don't guarantee an ex won't take half the marital assets, as pre-nups must be "fair". If you have $200k in assets, good luck getting a court to enforce a pre-nup that says your spouse of 5+ years is limited to 10% of your assets. They are definitely getting 50%. If you are worth $10 million, then that 10% clause might be ruled "fair" by the divorce court.

Pre-nups are most useful to split specific assets. For example, you specify you get to keep your $5 million horse farm upon marriage dissolution, but you pay your ex 40% of its value (of course "value" can be another legal fight). For the married med students and residents, keep in mind your medical license is considered an asset to be divided, which is a lot more vague/unfair than dividing an actual practice with actual value.



In the end, marriage is always a legal contract. She is basically like hospital HR: she wanted you to sign the standard contract with zero changes, but you wanted a negotiated contract.

The best way to protect yourself is to just not get married in the first place. Or choose very very wisely. I say this as someone who is getting married this year and went through the pre-nup process. There are so many ways to get “screwed” in a divorce even when a pre-nup is in place. You never know how people can change years down the road.
 
The best way to protect yourself is to just not get married in the first place. Or choose very very wisely. I say this as someone who is getting married this year and went through the pre-nup process. There are so many ways to get “screwed” in a divorce even when a pre-nup is in place. You never know how people can change years down the road.
You really don't know how people change over the years. In life and in work, nothing is a surprise anymore. But, you can always keep yourself well prepared to protect yourself. This segways back into the original post. I would never open with a business partner. Start things yourself and be careful who you allow access to for major things like the business bank account. I never had a business partner and I'm the only one with financial access. Conflicts commonly arise. Business is high risk but also high potential gain....
but also high risk LOL

Money changes people and it can get brutal. Or maybe the more accurate thing to say is, it can bring out the worst in people. You never truly know someone.
 
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A business is usually valued at around 3X EBITDA. If you have other psychiatrists, that X might go higher. If you have only you, or opened up last year, that X might go lower.

Does 3x EBITDA apply for private practices that is self-running (i.e. one that has other psychiatrists or extenders with efficient billing process and marketing pipeline for new patients and solid backend support)? I think that's steep. I'm not sure a solo practice would even justify 1x EBITDA. It's like paying someone more than their annual earning to take over their job.

How timely haha


Does this mean my future side gig as a guy sugar baby for sugar momma is less likely to succeed than Becky's sugaring for a sugar daddy? There goes the pivot in my career.

The best way to protect yourself is to just not get married in the first place. Or choose very very wisely. I say this as someone who is getting married this year and went through the pre-nup process. There are so many ways to get “screwed” in a divorce even when a pre-nup is in place. You never know how people can change years down the road.

So why marry? You know what to do optimally and it's not marriage.

You really don't know how people change over the years. In life and in work, nothing is a surprise anymore. But, you can always keep yourself well prepared to protect yourself. This segways back into the original post. I would never open with a business partner. Start things yourself and be careful who you allow access to for major things like the business bank account. I never had a business partner and I'm the only one with financial access. Conflicts commonly arise. Business is high risk but also high potential gain....
but also high risk LOL

Money changes people and it can get brutal. Or maybe the more accurate thing to say is, it can bring out the worst in people. You never truly know someone.

Chica, you're just a fountain of wisdom. There is a saying that the person you see in divorce is not the same person you married. Money really changes things, even among blood. I've heard of siblings not talking to each other over fight over father's estate.

You have to be very very careful about who you partner with in life and in business. Stories of practice managers embezzling from doctors is not uncommon, especially if the doctors are not financially savvy and don't check on the managers to keep the latter accountable.

Although technological progress will eliminate jobs, the silver lining is the decreased need for business partners or employees will reduce chance of loss from human error or greed.
 
Does 3x EBITDA apply for private practices that is self-running (i.e. one that has other psychiatrists or extenders with efficient billing process and marketing pipeline for new patients and solid backend support)? I think that's steep. I'm not sure a solo practice would even justify 1x EBITDA. It's like paying someone more than their annual earning to take over their job.

You're over-estimating the worth of a solo practice. It is probably worth the depreciated value of the furniture, and $10k worth of leads that will produce diminishing returns/patient attrition within 6 months. When you want you to sell, everyone will assume you are selling because:

a. the business is declining (i.e., worthless)
b. there is some pending liability (i.e., negative value).

Many older docs let their productivity decline until it is too late to sell anything, or hire anyone to take over.
 
Can you tell me about residential work? I’ve been interested in this for myself but have no experience with it.
I'm a CAP in a residential eating disorders program, so I don't know how much my experience generalizes to other residential programs. In my program, patients will come live in our home (was some rich person's vacation home, or something) which is in a nature setting, far from other homes. They have several hours of group therapies per day (even on weekends), structured meals, and some time for school. They see a therapist for individual therapy twice per week, family therapy once per week, dietitian sessions 1-2 times per week, and then see me. They do get to talk to and see their family. We take them on some outings when we know we can trust them. We do also do some sessions that prepare them for experiences back at home (restaurant outings, meals with family, clothes shopping, grocery shopping, food preparation, etc).

Things I enjoy:
-Flexibility in schedule. I have to see each patient once per week, so if I need to take off one day or come in late or leave early, I can just do it. I can change my schedule without notice most of the time since I won't have anyone truly "scheduled." I can also see some patients for more frequent, shorter visits when that works better. They already have lots of therapies throughout the week.

-Good team cohesion. We have therapists, dietitians, nurses, and mental health techs all working together with each patient. It helps that the staff where I am are actually competent. But in general, I like being able to discuss patients and share some of the responsibilities and family work.

-Patients are of a high acuity. I find treating sicker patients more interesting, and that also helps us see them improve more dramatically. I also get to address some non-psychiatric medical issues, which I enjoy. We have nursing on site 24/7, and they serve as a good first line for medical concerns.

-I only have to see patients for the 1-3 months they're with us. In the outpatient world, I would keep many patients for years. Many patients I liked, but some were draining. Some wanted me to try solving all their life's problems, and keeping up those boundaries gets tiring. In residential care, we explicitly set out to treat one main problem (of course, we do have to address comorbidities, at least to some extent) and then send the patients out to lower levels of care.

-Patients are contained. I felt that in outpatient, I spent a lot of time bashing my head against the wall of patients just not being in a good place. But in residential, they have structure, set sleep/wake times, regular meals, and good support. They don't have their cell phones or social media. I sometimes wonder if I'm actually doing anything to treat patients or if it's just the environment. Regardless, it feels nice to not have those lifestyle variables always interfering.

As for downsides:
-I have to alternate call with the other psychiatrist. One of us has to be available overnight and on weekends. However, we are rarely called to do anything as we take care of enough during the week. I don't need to come in off-hours as in an emergency, they should call 911 and get the patient to an ED anyway.

-We are a facility with many regulations from the state and from Joint Commission. We also have to interact with insurance companies and follow their rules. We sometimes have to fight with insurance to avoid a patient having to discharge prematurely.
 
I'm a CAP in a residential eating disorders program, so I don't know how much my experience generalizes to other residential programs. In my program, patients will come live in our home (was some rich person's vacation home, or something) which is in a nature setting, far from other homes. They have several hours of group therapies per day (even on weekends), structured meals, and some time for school. They see a therapist for individual therapy twice per week, family therapy once per week, dietitian sessions 1-2 times per week, and then see me. They do get to talk to and see their family. We take them on some outings when we know we can trust them. We do also do some sessions that prepare them for experiences back at home (restaurant outings, meals with family, clothes shopping, grocery shopping, food preparation, etc).

Things I enjoy:
-Flexibility in schedule. I have to see each patient once per week, so if I need to take off one day or come in late or leave early, I can just do it. I can change my schedule without notice most of the time since I won't have anyone truly "scheduled." I can also see some patients for more frequent, shorter visits when that works better. They already have lots of therapies throughout the week.

-Good team cohesion. We have therapists, dietitians, nurses, and mental health techs all working together with each patient. It helps that the staff where I am are actually competent. But in general, I like being able to discuss patients and share some of the responsibilities and family work.

-Patients are of a high acuity. I find treating sicker patients more interesting, and that also helps us see them improve more dramatically. I also get to address some non-psychiatric medical issues, which I enjoy. We have nursing on site 24/7, and they serve as a good first line for medical concerns.

-I only have to see patients for the 1-3 months they're with us. In the outpatient world, I would keep many patients for years. Many patients I liked, but some were draining. Some wanted me to try solving all their life's problems, and keeping up those boundaries gets tiring. In residential care, we explicitly set out to treat one main problem (of course, we do have to address comorbidities, at least to some extent) and then send the patients out to lower levels of care.

-Patients are contained. I felt that in outpatient, I spent a lot of time bashing my head against the wall of patients just not being in a good place. But in residential, they have structure, set sleep/wake times, regular meals, and good support. They don't have their cell phones or social media. I sometimes wonder if I'm actually doing anything to treat patients or if it's just the environment. Regardless, it feels nice to not have those lifestyle variables always interfering.

As for downsides:
-I have to alternate call with the other psychiatrist. One of us has to be available overnight and on weekends. However, we are rarely called to do anything as we take care of enough during the week. I don't need to come in off-hours as in an emergency, they should call 911 and get the patient to an ED anyway.

-We are a facility with many regulations from the state and from Joint Commission. We also have to interact with insurance companies and follow their rules. We sometimes have to fight with insurance to avoid a patient having to discharge prematurely.
Thank you. That sounds really interesting. I really like the idea of seeing the patient for a few months then saying goodbye and having so much support. How many patients are you seeing on a daily basis?
 
I do PP. I was doing telehealth for a large private company and got burnt out. I’ll share some advice.

1. Hire an accountant.
2. Become an LLC first. Get taxed as an S corp. pay yourself a reasonable salary as an employee of your own company. The rest is owner distributions which avoids some parts of taxation.
3. I use Alma for billing. It works fine. Your rates are correct. I get about $150ish for a 99214 and $80ish for 90833 so most of my encounters (30 mins) are about $230, or $460 per hour. I have almost no overhead and work about 24 patient facing hours a week.
4. The rest of my “work time” is scheduling, emails, and adding new patients to my system. Don’t forget about that time.

I’m much happier, I can make more money and work less. I always have an endless supply of patients because I’m in network with almost all insurances.
 
I'm 100% positive! I've asked other psychiatrists in my area and have heard the same things from both. I should preface this by saying that I live in a state where we have insurance companies that do not exist elsewhere. So the main insurance companies that we utilize are likely not utilized by other psychiatrists in the US.
Which state? My rates are similar to what you say and we have ones that don’t exist elsewhere either
 
HW quoted me higher rates for Aetna, but Alma was higher for Cigna. I would rather not pay the monthly fee to Alma/
 
Thank you. That sounds really interesting. I really like the idea of seeing the patient for a few months then saying goodbye and having so much support. How many patients are you seeing on a daily basis?
It's expected that I can have up to 12-14 patients at a time, with 2-3 admissions/discharges per week. That works out to 2-3 patients seen per day, on average. But I might also attend a family session once, a discharge session, and various team meetings. We are a growing program still so there's a lot of administrative tasks to help design it well, which I enjoy.
 
It's expected that I can have up to 12-14 patients at a time, with 2-3 admissions/discharges per week. That works out to 2-3 patients seen per day, on average. But I might also attend a family session once, a discharge session, and various team meetings. We are a growing program still so there's a lot of administrative tasks to help design it well, which I enjoy.
Wow that sounds amazing
 
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