Very small private practice vs locums to maintain clinical experience?

[wish i was at the lake]

I’m >5 years out of psych residency and extremely burned out, made a job change last year in hopes of improvement though have ended up even more crispy. I’m planning to discuss going part time with my current supervisor but I anticipate the answer will be no so I am working on my contingency plan.
I’d like to take a significant break before jumping back in, and want to maintain some clinical experience while I’m sorting things out. I think it’s feasible to start a private practice, with goal of keeping it very small and cash only initially, as I’ve thought about going that route anyway given my negative experience as an employed psychiatrist, though locums might make more sense as an interim way to maintain my skills.
I’d greatly appreciate input from others who’ve taking a break or who have considered this themselves, as I am trying not to rush into a decision despite wishing I could quit right now.

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[mistafab]

Just wanted to share empathy for you. What part do you still enjoy about the field in general, if you can name anything?

May be helpful to know what parts of your experience grinds you the most.

 

[littlefred]

Care to elaborate (without doxxing yourself of course) about why you think you are burned out?

 

[nexus73]

locums is the least tied down and no startup costs. if private practice starts to be a grind your can close it, but it’s a bit more involved as you may know. Plus PP has startup costs.

 

[Sushirolls]

I weighed similar calculus years ago. Locums is not a solution to burn out. It's just another hot oven. So rather than being baked, now you are being convection baked. Just another way to make you crispy.

If you can financially say meh, go PP. Its the best way to keep you in the game.

 

[jbomba]

Why not work for a group part-time?

 

[Celexa]

locums is the least tied down and no startup costs. if private practice starts to be a grind your can close it, but it’s a bit more involved as you may know. Plus PP has startup costs.

Locums is the least power and the worst jobs. I can't imagine anything that would burn me out faster and it's hard to imagine that helping the OP. You do need hustle to start up a private practice, but at least it's your own hustle.

 

[ksharp33]

could do locums as a way to bridge yourself to PP.

 

[Trismegistus4]

Locums is the least power and the worst jobs. I can't imagine anything that would burn me out faster and it's hard to imagine that helping the OP. You do need hustle to start up a private practice, but at least it's your own hustle.

I did locums for a year and enjoyed it. I didn't find the assignments worse than any other job. If I were looking to take a break, I would almost certainly do it by lining up some part-time locums.

 

[Merovinge]

I'd see if there are any local MD lead/owned groups that make sense to join, many would have options to do this on a PT basis. If it's quality of the care you are providing that is lacking, this would make the most sense to me. If it's the utter grind of number of patient's seen each day, PHP/IOP jobs tend to have the lowest number of encounters per day.

If it's something more fundamental to psychiatry or medicine or your life, I think there is nothing wrong with taking a leap into the void and spending a month traveling, doing a mindfulness retreat for a week, or as your name implies just spending some time alone at the lake. It will not be hard to get back into work after a brief break from practice, we have the luxury of knowing the demand is there for the work.

 

[troutscout]

I worked locums for 9 months while I got my cash pay private practice off the ground and it was helpful to have the financial cushion but if you're burned out from the system, you'll still be "in the system" with locums. But like others have said, it is a nice bridge. I wouldn't want to work locums longterm because the jobs are kind of terrible. If you're burned out, take action and make some changes - if you need to leave, its okay to leave. I resigned from my outpatient psychiatry job and took a few months off to process and tend to my own mental health, and to start building my private practice. There are people like myself, and others, who offer PP consultation/coaching. It's very doable.

 

[wish i was at the lake]

I appreciate the varying perspectives, reflects my internal debate.

Without risking doxxing myself with specifics, I chose psychiatry because I liked that there weren’t labs or numbers that defined a diagnosis, that patients were complex puzzles to figure out with time and thoughtful formulation, and I enjoyed my residency in an idealistic academic environment with every resource available.

I am now in a rural-ish setting to be near family in an area with limited resources. I enjoy working with the majority of my patients, and particularly get satisfaction from patients who use the support and medications as a ladder to help them climb up to a better mental place. What has burned me out is the medicalization of the human experience, the small though time consuming proportion of patients and family who want a pill for every problem, admin only seeing physicians as RVU producing machines, lack of control over my caseload and schedule, and lack of therapists/nurses/support staff to help with setting boundaries (or even worse, who expertly deflect work towards me). Basically everything brought up in the moral injury thread.

My student loans are nearly paid off which has allowed me more freedom to think about what’s next. My primary worry is ensuring I don’t have a gap in my clinical work that would prevent me from getting another job in the future if needed, so it’s very encouraging to hear of people who were able to take some time off without it being a problem. I have some resources available (the positive of small town life) that would make a private practice a bit easier to set up which helps lower the barrier to entry a bit. There is one MD led private practice nearby that I could look into, though they had advertised for a part-time MD offering $100/hour as a 1099 in the past which was not enticing.

I also very much appreciate those who have shared their experiences with starting private practices as I will certainly be using that guidance if I go that route! And I’ll be sure to pay it forward with sharing my own experience when the time comes.

 

[TexasPhysician]

While I enjoy private practice, it isn’t without stressors. Hiring, firing, payroll, leases, and designing everything from the ground up is unpaid work. If you aren’t planning to do it 20+ hours/week, I wouldn’t recommend it. I know some do it, but I never would.

While some locum jobs are terrible, there are also some that are just poor locations or boring work. Sometimes the boring work is a good way to recharge you batteries. I did a locum job that was essentially 3 easy evals in 8-12 hour shifts. The rest of the time you could go on a walk, shoot hoops, read a book, or whatever. I think the pay was only $175/hr. They did pay for the hotel as well.

 

[nexus73]

It may also be worth calling around to psych units in your relative vicinity to see if they have need for a PRN doc, or someone for weekend coverage occasionally. Many psych units have little to no bench to fill in if someone needs vacation time or maternity leave. If you find a few hospitals like this that would pay for your travel and hotel if needed, you could make some money and keep clinical work going.

Maybe look at a university health clinic, pay is often lower end, but the work is usually not demanding.

 

[hippopotamusoath]

Seconding the idea that contingent weekend hospital coverage could be a great fit if you like that kind of environment, and if that type of work is available. It would be fewer total hours, light work usually (just maintaining meds or making small changes, no discharges), and it would give you some autonomy back in that you can sign up for what you have the energy for.

 

[Jules A]

Weekend work can be pleasant and lucrative. Depending on your financial needs one weekend or two a month in addition to a small out of network practice might be an ideal mix and yield a decent income. I get referrals from ED/units from hospitals where I moonlight.

For private practice it is helpful to have psychologist and therapist contacts in the community for referrals. They may be willing to offer a one or two day per week office share which would reduce your start up costs to only a couple of thousand dollars and provide referrals. The majority of my clients want virtual now anyway so I am glad I didn’t lease an entire office. Please keep us updated and I hope you find a balance that allows you to enjoy your work.

 

[smalltownpsych]

Weekend work can be pleasant and lucrative. Depending on your financial needs one weekend or two a month in addition to a small out of network practice might be an ideal mix and yield a decent income. I get referrals from ED/units from hospitals where I moonlight.

For private practice it is helpful to have psychologist and therapist contacts in the community for referrals. They may be willing to offer a one or two day per week office share which would reduce your start up costs to only a couple of thousand dollars and provide referrals. The majority of my clients want virtual now anyway so I am glad I didn’t lease an entire office. Please keep us updated and I hope you find a balance that allows you to enjoy your work.

Second this, if you were in my area, I have an office and patients available for all cash pay. A more rural area like you are talking about means probably going to want to accept insurance, but if there is a good psychologist practice in town I am sure that they would have most infrastructure set up and you could just focus on what you like to do. Also, means support for patients in crisis so you don’t have to do that alone and my experience has been that rarely does psychiatry need to be bothered for crises. One thing we can’t help with much are the med refill calls so that’s something to think about.

 

[kitsens]

Locums full time out of the question, or if one does, same issues of full time somewhere but different flavor of ice cream. Some gigs are home runs and the only reason I didn't stay was because the geographic location, etc. For the ones that uncomfortable, you terminate the contract which is common and expected in locums. If you choose wisely, keep assignment shorts, and make it clear to facilities you are a short term physician there (2-6 months), locums great way to kick the can the down the road while you assess options. Easy to do PP now, virtual, may not (or may 🙂 ) do great financially. For all the problems with psychiatry and income, if you can let go of income, you can definitely safely, reasonably make 1st and second base hits while you organize yourself.

 

[wish i was at the lake]

Update - I left my last job and am now working 0.5FTE in a different system with a program that is a much better fit clinically for me. The program itself has strong boundaries around my responsibilities and I have fantastic coworkers who share the workload. When I’m off, I’m off and I am not worried about what I’m coming back to, so nice to not have the Sunday Scaries anymore! I’m incredibly appreciative of the support I received here, it’s interesting looking back at my posts and seeing the ‘indentured servant’ mindset I had, compared with the freedom/control I feel now. It certainly helped paying off my student loans and no longer having that burden weighing over me.

 

[Merovinge]

Update - I left my last job and am now working 0.5FTE in a different system with a program that is a much better fit clinically for me. The program itself has strong boundaries around my responsibilities and I have fantastic coworkers who share the workload. When I’m off, I’m off and I am not worried about what I’m coming back to, so nice to not have the Sunday Scaries anymore! I’m incredibly appreciative of the support I received here, it’s interesting looking back at my posts and seeing the ‘indentured servant’ mindset I had, compared with the freedom/control I feel now. It certainly helped paying off my student loans and no longer having that burden weighing over me.

Absolutely spot on. This is why it is so important to have a strong understanding of your finances, it does literally impact your ability to practice medicine.

 

[psychmd03]

It may also be worth calling around to psych units in your relative vicinity to see if they have need for a PRN doc, or someone for weekend coverage occasionally. Many psych units have little to no bench to fill in if someone needs vacation time or maternity leave. If you find a few hospitals like this that would pay for your travel and hotel if needed, you could make some money and keep clinical work going.

Maybe look at a university health clinic, pay is often lower end, but the work is usually not demanding.

This would be my thought check into IP units for prn coverage. Two weekends a month should be able to get you 6-12k a month depending on volume. That will keep some money coming in and experience while massively decreasing work.

I’m starting to think about a way to coast after another 1.5-2y so I’m interested in other ideas that might pop up in this thread

 

[nexus73]

Update - I left my last job and am now working 0.5FTE in a different system with a program that is a much better fit clinically for me. The program itself has strong boundaries around my responsibilities and I have fantastic coworkers who share the workload. When I’m off, I’m off and I am not worried about what I’m coming back to, so nice to not have the Sunday Scaries anymore! I’m incredibly appreciative of the support I received here, it’s interesting looking back at my posts and seeing the ‘indentured servant’ mindset I had, compared with the freedom/control I feel now. It certainly helped paying off my student loans and no longer having that burden weighing over me.

do you have health insurance through the 0.5 FTE job, or access to coverage in another way?

 

[Merovinge]

This would be my thought check into IP units for prn coverage. Two weekends a month should be able to get you 6-12k a month depending on volume. That will keep some money coming in and experience while massively decreasing work.

I’m starting to think about a way to coast after another 1.5-2y so I’m interested in other ideas that might pop up in this thread

I think you'll find an echo of folks who run their own cash private practices of having very high job satisfaction. You provide a brief phone screen (for free) to make sure it's worth doing the initial consult. If you don't mesh with the patient, you simply move them onwards. You can exactly set your hours, keep a low overhead, and work 10-15 hours clinically a week while still providing significant income. You will need some connections in an area to get started (or at least accelerate the start), but if you aren't trying to be too busy, I don't think it's as big of an ask.

Few ED shifts or weekend IP coverage where you never are responsible for dispo/legal/med changes both can work but the acuity is just so much higher.

 

[wish i was at the lake]

do you have health insurance through the 0.5 FTE job, or access to coverage in another way?

Yup! Full access to benefits at 0.5, otherwise I probably would have gone with 0.4

 

[SeniorWrangler]

The problem with a small practice is, you still need all the same stuff but have fewer patients to pay down the fixed costs. If you can keep your costs really liw, it can work well.
But if you’re really burned out, maybe one of those inpatient or ED coverage gigs would be better, where you can forget everything the moment you clock out…

 

[psychmd03]

I think you'll find an echo of folks who run their own cash private practices of having very high job satisfaction. You provide a brief phone screen (for free) to make sure it's worth doing the initial consult. If you don't mesh with the patient, you simply move them onwards. You can exactly set your hours, keep a low overhead, and work 10-15 hours clinically a week while still providing significant income. You will need some connections in an area to get started (or at least accelerate the start), but if you aren't trying to be too busy, I don't think it's as big of an ask.

Few ED shifts or weekend IP coverage where you never are responsible for dispo/legal/med changes both can work but the acuity is just so much higher.

Good thought in the PP right now in my head I struggle with being tied down to specific times but almost everything mini IP requires that so it might be something I have to just deal with the idea of seeing 10-15 patients OP a week just to keep some cash and prevent full skill deterioration.