What are private practice patients like?

[toocoolforschool]

Hi everyone, first time I'm posting here!
I'm really interested in psychiatry and the neuroscience behind the disorders. However due to reasons of autonomy, I would prefer to work in a private practice environment where I would be able to dictate my own hours and my own niche. Unfortunately, I have been unable to undertake rotations/get experiences in private practice psychiatry. (side note: does anyone know how a medical student might get exposure to this area?)

Everyone is telling me how different private practice patients are. Would anyone mind telling me what that means and what kind of patients/interactions you have in private practice? I'm pretty interested in anorexia and addiction medicine.

I also really like the field, the only thing I'm worried about is getting emotionally abused - unfortunately when a patient makes a nasty comment to me I often think about it months later and this is also another reason why I'm trying to avoid inpatient psychiatry as well. I know that this probably is unavoidable in all aspects of medicine but would private practice psychiatry avoid some of this - especially when I'm interested in high end psychotherapy as well?

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[clausewitz2]

Hi everyone, first time I'm posting here!
I'm really interested in psychiatry and the neuroscience behind the disorders. However due to reasons of autonomy, I would prefer to work in a private practice environment where I would be able to dictate my own hours and my own niche. Unfortunately, I have been unable to undertake rotations/get experiences in private practice psychiatry. (side note: does anyone know how a medical student might get exposure to this area?)

Everyone is telling me how different private practice patients are. Would anyone mind telling me what that means and what kind of patients/interactions you have in private practice? I'm pretty interested in anorexia and addiction medicine.

I also really like the field, the only thing I'm worried about is getting emotionally abused - unfortunately when a patient makes a nasty comment to me I often think about it months later and this is also another reason why I'm trying to avoid inpatient psychiatry as well. I know that this probably is unavoidable in all aspects of medicine but would private practice psychiatry avoid some of this - especially when I'm interested in high end psychotherapy as well?

High end private practice psychotherapy = more narcissists = more people acting dismissive toward you.

It's normal to not want people to be sh*try to you but you misunderstand the power dynamic here. As the psychiatrist you are the one with way more status and authority, I am not sure most patients can emotionally abuse you in a meaningful way. A preschooler can scream that they hate you but it is not emotionally abusing you, it is just throwing a tantrum/acting like an assh*le.

You are just not in a subordinate position here.

 

[birchswing]

High end private practice psychotherapy = more narcissists = more people acting dismissive toward you.

It's normal to not want people to be sh*try to you but you misunderstand the power dynamic here. As the psychiatrist you are the one with way more status and authority, I am not sure most patients can emotionally abuse you in a meaningful way. A preschooler can scream that they hate you but it is not emotionally abusing you, it is just throwing a tantrum/acting like an assh*le.

You are just not in a subordinate position here.

I agree, but reminded me of something funny:

 

[TexasPhysician]

Private practices can vary significantly. Are we talking a pp that takes Medicaid, avg cash pay only, commercial insurance only, high end psychotherapy focused, etc.?

 

[romanticscience]

I've only worked in private practice, so I'm comparing this to community mental health clinic-patients from residency. My private practice has patients with good commercial insurance or who pay cash.

Some people act entitled (seems to be more associated with cash patients) but most are reasonable and enjoyable with which to work. Most patients are employed, have a college or advanced degree, and have fairly stable relationships. It a sense, they will want you to be personable, evidence-based, and flexible because they have the option to seek treatment elsewhere. When I was a resident, patients were dependent on the system and it allowed providers to be crappy, there was no selection for quality. This is why I like private practice; I'm rewarded for quality care. I'm realizing that I'm not successful because I charge outrageous fees but because my personality retains patients and reduces no-shows. People like to come to their appointment; that's how it should be, not because they're scared they'll be discharged and lose their meds.

Also, my patients are extremely interesting. They come from all different walks of life. I think this is because I take insurance. If I were cash only, it would be CEO after surgeon after lawyer, all day. It's fun learning about the lives of police officers, teachers, bakers, musicians, psychologists, philosophers, pastors, porn-stars...

I believe there's a quote about the only person being able to cheat death is the therapist because of their ability to be in more than one life.

This type of psychiatry practice is amazing but it's hard to learn. Many residencies have attendings who never left the system and whose practices have been molded by that culture. It was difficult to find mentors because those are the type of people who leave academia. Granted, there are residency mentors like this but they tend to be at bigger name programs on the coasts (eg, Cornell or Columbia) who maintain side private cash practices and leverage their IVY league academic title. Regardless of your belief in psychoanalytic theory, the practice can teach you a lot about private practice. In my residency, I had a private practice analyst supervisor. Although he was a PhD, it was helpful to see his office, hear how he billed, scheduled clients, etc. Oh, and how defense mechanisms work lol.

 

[TexasPhysician]

My private practice has patients with good commercial insurance or who pay cash.

Some people act entitled (seems to be more associated with cash patients).

Also, my patients are extremely interesting. They come from all different walks of life. I think this is because I take insurance. If I were cash only, it would be CEO after surgeon after lawyer, all day. It's fun learning about the lives of police officers, teachers, bakers, musicians, psychologists, philosophers, pastors, porn-stars...

This is a common misperception by people who take insurance. While I’m cash only, we have the same patient demographic. I see teachers, police officers, Medicaid recipients, pastors, realtors, etc on a routine basis. I don’t have a single surgeon in my practice. I have enough physician patients to count on 1 hand. If anything, my patients with the better commercial policies are the highest
maintenance. In sporadic cases, they’ll say they have great insurance, so they can replace me tomorrow. Then they are back apologizing.

My fees are reasonable like most cash practices in my opinion. Sure there are a few that charge $600/hr away of the coasts, but that is few and far between.

I could probably earn a lot more money by taking commercial plans, focusing on my billing codes, and shortening my visits a bit. I prefer a little increased time with patients and low overhead.

 

[AD04]

Most patients that pay cash or have better insurance act normal and civilized. They will ask questions to education themselves such as why you're using a particular medication or side effects and when they will start feeling better. That's ok because you should have answers as to why you're treating in a particular way. And questions will keep you sharp, especially if they do their own reading and ask you about that.

Then there are those that are more entitled or even hostile. You have to know how to set boundaries. They may complain at first but if you're firm, time they may acquiesce. Those who continue to be toxic should be discharged.

If you're doing private practice right, you should have maximized autonomy first. Maximum autonomy will help you enjoy your career to the fullest extent. Therefore, you can discharge patients who emotionally abuse you. No worries about that.

In sporadic cases, they’ll say they have great insurance, so they can replace me tomorrow. Then they are back apologizing.

Why do they come back if they have great insurance?

I noticed that no-shows are higher with cash patients. What do you do to keep the no-show rate down?

 

[birchswing]

This is a common misperception by people who take insurance. While I’m cash only, we have the same patient demographic. I see teachers, police officers, Medicaid recipients, pastors, realtors, etc on a routine basis. I don’t have a single surgeon in my practice. I have enough physician patients to count on 1 hand. If anything, my patients with the better commercial policies are the highest
maintenance. In sporadic cases, they’ll say they have great insurance, so they can replace me tomorrow. Then they are back apologizing.

My fees are reasonable like most cash practices in my opinion. Sure there are a few that charge $600/hr away of the coasts, but that is few and far between.

I could probably earn a lot more money by taking commercial plans, focusing on my billing codes, and shortening my visits a bit. I prefer a little increased time with patients and low overhead.

The people you see who are Medicaid recipients . . . have they disclosed that? Maybe Texas is different than where I live. Where I am you can't take fee for service from Medicaid patients, which can put people in a jam. I don't want to say too much in case I am identifiable by things I've posted, but a friend of mine has taken a don't ask don't tell approach which has caused anxiety. Also it seems like some doctors are unaware in my area of this rule, especially when Medicaid is secondary. Some doctors think secondary status doesn't prevent them from seeing them, when from my reading of the law, it does. A friend of mine finally told their therapist because it had been a bubbling concern that it would come to light eventually which caused anxiety, but the therapist was willing to remain ignorant allowing my friend to continue paying cash for the service. There was also a federal rule change in 2014 that prescriptions by non-Medicaid providers cannot be covered by Medicaid. So even if you get to see a non-Medicaid doctor, it can be expensive for filling scripts. There is an exception for ORP providers, which to make a long story short, from my recollection is like dipping your toe into Medicaid but not being a full-fledged provider.

 

[keolu hills]

High end private practice psychotherapy = more narcissists = more people acting dismissive toward you.

It's normal to not want people to be sh*try to you but you misunderstand the power dynamic here. As the psychiatrist you are the one with way more status and authority, I am not sure most patients can emotionally abuse you in a meaningful way. A preschooler can scream that they hate you but it is not emotionally abusing you, it is just throwing a tantrum/acting like an assh*le.

You are just not in a subordinate position here.

Get off your high horse. You can have patients with just as much education. Don't ass u me that your patients will all be illiterate and uneducated.

 

[clausewitz2]

Get off your high horse. You can have patients with just as much education. Don't ass u me that your patients will all be illiterate and uneducated.

I am not sure where you got anything about people being illiterate and uneducated from, that's something you're bringing to the table.

It doesn't matter if someone is a Nobel Laureate, when you go into a situation where one of you is spilling their guts about sensitive details of their inner lives and the other is disclosing almost nothing, you have an asymmetrical relationship. That's even setting aside the fact that only one of you had a prescription pad or the fact that if you fire then you are going to fill their slot way faster than they are going to see a new psychiatrist. You are the one with the power in this situation.

Now, if you are emotionally involved to the extent they can hold you hostage via your anxiety or desire to be loved, well...you may not be the one with the power, but you are doing it wrong. If you think about how you can't control them and your reaction is not "yeah, I guess not, at the end of the day" but "oh god oh god oh god" you need to revisit how you are relating to your patients.

 

[romanticscience]

I noticed that no-shows are higher with cash patients. What do you do to keep the no-show rate down?
[/QUOTE]

Text reminders 48-hours before the appointment with the option to cancel and the link to my portal to reschedule.

Re-schedule within the business week: No penalty
First no-show or late cancellation for the year: $0.01
Subseqent no-show or late cancellation for the year: $150

* I tried charging my full fee but felt really uncomfortable about it. So, I halved it. I kind of know by the 30-min mark they're not coming, so I can fill it with productive work. You have to FEEL that your billing practices are fair to be able to enforce them.

If someone has trouble paying the late fee, I sometimes will finance it.

 

[SourceOfDenial]

Most patients that pay cash or have better insurance act normal and civilized. They will ask questions to education themselves such as why you're using a particular medication or side effects and when they will start feeling better. That's ok because you should have answers as to why you're treating in a particular way. And questions will keep you sharp, especially if they do their own reading and ask you about that.

Then there are those that are more entitled or even hostile. You have to know how to set boundaries. They may complain at first but if you're firm, time they may acquiesce. Those who continue to be toxic should be discharged.

If you're doing private practice right, you should have maximized autonomy first. Maximum autonomy will help you enjoy your career to the fullest extent. Therefore, you can discharge patients who emotionally abuse you. No worries about that.

I can’t figure out if you’re a doctor or a dog trainer

 

[TexasPhysician]

Most patients that pay cash or have better insurance act normal and civilized. They will ask questions to education themselves such as why you're using a particular medication or side effects and when they will start feeling better. That's ok because you should have answers as to why you're treating in a particular way. And questions will keep you sharp, especially if they do their own reading and ask you about that.

Then there are those that are more entitled or even hostile. You have to know how to set boundaries. They may complain at first but if you're firm, time they may acquiesce. Those who continue to be toxic should be discharged.

If you're doing private practice right, you should have maximized autonomy first. Maximum autonomy will help you enjoy your career to the fullest extent. Therefore, you can discharge patients who emotionally abuse you. No worries about that.



Why do they come back if they have great insurance?

I noticed that no-shows are higher with cash patients. What do you do to keep the no-show rate down?

I stay on time, provide good care, and I do telepsych. Some go try another doctor and wait 2 hours in the waiting room to be seen for half the time I spend. Sometimes it takes seeing the alternative to appreciate what you had.

I charge the full fee for a no show. I make it clear that you are paying to reserve my time, nothing more. Additionally those that aren’t there 5 min after their time slot get a phone call to convert to telepsych or phone visit. I also have a reminder system. Very few don’t show.

 

[Attending1985]

I've only worked in private practice, so I'm comparing this to community mental health clinic-patients from residency. My private practice has patients with good commercial insurance or who pay cash.

Some people act entitled (seems to be more associated with cash patients) but most are reasonable and enjoyable with which to work. Most patients are employed, have a college or advanced degree, and have fairly stable relationships. It a sense, they will want you to be personable, evidence-based, and flexible because they have the option to seek treatment elsewhere. When I was a resident, patients were dependent on the system and it allowed providers to be crappy, there was no selection for quality. This is why I like private practice; I'm rewarded for quality care. I'm realizing that I'm not successful because I charge outrageous fees but because my personality retains patients and reduces no-shows. People like to come to their appointment; that's how it should be, not because they're scared they'll be discharged and lose their meds.

Also, my patients are extremely interesting. They come from all different walks of life. I think this is because I take insurance. If I were cash only, it would be CEO after surgeon after lawyer, all day. It's fun learning about the lives of police officers, teachers, bakers, musicians, psychologists, philosophers, pastors, porn-stars...

I believe there's a quote about the only person being able to cheat death is the therapist because of their ability to be in more than one life.

This type of psychiatry practice is amazing but it's hard to learn. Many residencies have attendings who never left the system and whose practices have been molded by that culture. It was difficult to find mentors because those are the type of people who leave academia. Granted, there are residency mentors like this but they tend to be at bigger name programs on the coasts (eg, Cornell or Columbia) who maintain side private cash practices and leverage their IVY league academic title. Regardless of your belief in psychoanalytic theory, the practice can teach you a lot about private practice. In my residency, I had a private practice analyst supervisor. Although he was a PhD, it was helpful to see his office, hear how he billed, scheduled clients, etc. Oh, and how defense mechanisms work lol.

What is your practice set up like? Are you solo or in a group? Do you do therapy?

 

[Sushirolls]

1) one time freebie for no show / late cancellation for duration of treatment
2) thereafter is $30 fee
3) Once I'm clinically full and those time slots have a greater relative value to myself and other potential patients, I'm going to increase the fee rate to $125 for 30 minute follow up, or $375 or $300 for a consultation slot.

 

[finalpsychyear]

As much as private practice is great in ways that it allows autonomy it does require behind the scenes work at least for those taking insurances.
Not sure those who do this 4-5 days a week at a high pace like it. I feel for me the sweet spot is about 15 hours of high paced work. This is balanced by telepsych which is super slow paced but well worth being able to wear pajamas even though the opportunity cost is massive on an hourly base.

 

[romanticscience]

What is your practice set up like? Are you solo or in a group? Do you do therapy?

Solo, about 70% therapy (60 min appts, q1-2 weeks)/20% medication (30-min appts, q1-3 month)/10% forensic consulting (doc review, report writing, evals). This week, I had 32 full hour appts, and 12 half hour appts.

I have a panel of ~ active 150 patients. 40 hours of face-to-face clinical hours per week. No weekends. No secretary, no biller, no nurse. Small office, very efficient, use a lot of technology.

 

[meow1985]

Hi everyone, first time I'm posting here!
I'm really interested in psychiatry and the neuroscience behind the disorders. However due to reasons of autonomy, I would prefer to work in a private practice environment where I would be able to dictate my own hours and my own niche. Unfortunately, I have been unable to undertake rotations/get experiences in private practice psychiatry. (side note: does anyone know how a medical student might get exposure to this area?)

Everyone is telling me how different private practice patients are. Would anyone mind telling me what that means and what kind of patients/interactions you have in private practice? I'm pretty interested in anorexia and addiction medicine.

I also really like the field, the only thing I'm worried about is getting emotionally abused - unfortunately when a patient makes a nasty comment to me I often think about it months later and this is also another reason why I'm trying to avoid inpatient psychiatry as well. I know that this probably is unavoidable in all aspects of medicine but would private practice psychiatry avoid some of this - especially when I'm interested in high end psychotherapy as well?

I’m not sure about private practice, but I’ve worked in an outpatient practice with a wealthier population so here goes.

Many PP patients are probably pretty psychologically minded, motivated, and pleasant. But try—just *try* and deny a patient with low distress tolerance +/- a personality disorder and a hefty degree of entitlement their controlled substances in outpatient clinic, or tell them you do not agree that the Xanax or Adderall their prior MD prescribed them is appropriate. You will likely be in for a world of pain. If you are lucky, they will leave in a huff. If not... They will yell at you, invoke arguments of authority and their doctor family and friends’ alleged opinions. They will complain. If you have no boss, they may leave bad reviews or even go to the medical board. They will accuse you of treating them unfairly like drug addicts. They will not just yell, they will play mind games, guilt trip, and argue. That is the upsetting part — adults are much more sophisticated than kids throwing tantrums. And they may well come back and harangue you again for the meds you said were inappropriate. The only way that true private practice may be better is that you can tell them you will not see them anymore due to their behavior, and it can be your decision as opposed to appealing to the management.

At least in inpatient you can blame a system, the law, etc. more easily and make them the common enemy of sorts in an effort to get the patient to semi-align with you — I.e. I don’t like you and you don’t like me, but you’re involuntarily detained, and I’m just doing my job, so let’s figure out what needs to happen to hasten your discharge. In outpatient it actually gets a lot more personal than that—and for me at least, being attacked by my outpatients has felt much more personal and more painful. In inpatient, you’re more like ships passing in the night and you know the situation is extra bad for these folks, or maybe they are too ill to tell their left hand from the right, so you may even take it a little less personally.

 

[dl2dp2]

Private practice if done right, is pretty fabulous. No question about it.

However, the main issue is marketing, and the variation of private practice in every aspect is arguably greater than a facility job. If you work one CMHC you've worked at them all.

In general, if you want to do well in PP, especially if you want to do very well in PP, you should aim high in terms where you do residency and/or fellowship.

 

[Bartelby]

Additionally those that aren’t there 5 min after their time slot get a phone call to convert to telepsych or phone visit. I also have a reminder system.

Awesome idea. That should probably be a standard approach these days.

 

[AD04]

I can’t figure out if you’re a doctor or a dog trainer

Just someone who engages in a bit of operant conditioning.

 

[AD04]

At least in inpatient you can blame a system, the law, etc. more easily and make them the common enemy of sorts in an effort to get the patient to semi-align with you — I.e. I don’t like you and you don’t like me, but you’re involuntarily detained, and I’m just doing my job, so let’s figure out what needs to happen to hasten your discharge. In outpatient it actually gets a lot more personal than that—and for me at least, being attacked by my outpatients has felt much more personal and more painful. In inpatient, you’re more like ships passing in the night and you know the situation is extra bad for these folks, or maybe they are too ill to tell their left hand from the right, so you may even take it a little less personally.

It's good that you're self-aware because that'll help you cross off the jobs that you won't like and you'll have a higher chance of finding a job that you will like.

Lots of the people who tout private practice fit a particular mold (want to live in urban area, seek autonomy, seek lifestyle and do not want to work weekends). They are willing to deal with the entitlement that may come with the demographic they treat. So go with your gut feeling and work that inpatient job. If you don't like it, figure out what else you don't like and you can always switch to something better.

 

[sighchiatry]

Solo, about 70% therapy (60 min appts, q1-2 weeks)/20% medication (30-min appts, q1-3 month)/10% forensic consulting (doc review, report writing, evals). This week, I had 32 full hour appts, and 12 half hour appts.

I have a panel of ~ active 150 patients. 40 hours of face-to-face clinical hours per week. No weekends. No secretary, no biller, no nurse. Small office, very efficient, use a lot of technology.

If you're comfortable, would you be open to sharing/elaborating on the technology you use?

 

[romanticscience]

EMR

I use Office Ally 24/7. I've been tempted to switch to DrChrono or Luminello. However, I'm sort of tied to OA because I do my own billing/claim submission and it's integrated with a good free clearinghouse (Office Ally). Add on features include e-prescribe (free), e-controlled substance rx ($100/year), appointment reminders ($30/mo), practice management/accounting module (free), integrated credit card processing (Worldpay).

Patient Portal

The integrated patient portal with Office Ally is called patiently. Here patients message me; during our first visit, I tell them this is the best way to communicate with me. So, most of my contact with patients comes through here. Very rarely do people call and leave a message. Patients can see my availability and schedule their own appointments. Again, very rarely do people call and try and make an appointment. Many of my therapy patients schedule in-session and my med-management patients will nicely fill in the gaps in my schedule every month or so. There's a preference given if you're coming in every week.

Text Reminders

Patients get a text message 48h before their appointment. They press "2" if they want to cancel. In the text, are the links to patient portal (if they want to re-schedule) and doxy.me (telepsychiatry). These reminders are automatically tied to the scheduled appointment in EMR. There is 0 risk of making a mistake.

Phone/Fax

I use a business version of google voice, which is covered by BAA (HIPAA compliant). If you pay for enterprise voice, it comes with a # for an auto-attendant and a direct line. When people call they are asked if they are an existing patient (taken to prompt if the matter is non-urgent --> voicemail or to be directly connected --> calls my phone), new patient (given directions to go to my website to request appt because of high call volume), crisis resources (--> forwarded to crisis center), forensic (-->forwarded to my cell), other (--> voicemail). The voicemails are transcribed and emailed to me. The downside, is that google voice calls will show my direct line or anonymous (people won't answer this). So, to fix, I use the doximity dialer. This lets you call anyone and display any # you like (for me, the auto-attendant/main #). I also use doximity free fax #.

Other software

I use google business apps (sheets, docs, sites, forms, drive, voice). These are covered by BAA, as I mentioned. On my website, there is a google form with which new patients request consultations, with screening questions. These go into a google sheet. I'm emailed when I get a new request.

Computer

I use a google pixelbook/chromebook which is a 2 in 1 with a pen. Again everything integrated with google.

 

[VA Hopeful Dr]

I’m not sure about private practice, but I’ve worked in an outpatient practice with a wealthier population so here goes.

Many PP patients are probably pretty psychologically minded, motivated, and pleasant. But try—just *try* and deny a patient with low distress tolerance +/- a personality disorder and a hefty degree of entitlement their controlled substances in outpatient clinic, or tell them you do not agree that the Xanax or Adderall their prior MD prescribed them is appropriate. You will likely be in for a world of pain. If you are lucky, they will leave in a huff. If not... They will yell at you, invoke arguments of authority and their doctor family and friends’ alleged opinions. They will complain. If you have no boss, they may leave bad reviews or even go to the medical board. They will accuse you of treating them unfairly like drug addicts. They will not just yell, they will play mind games, guilt trip, and argue. That is the upsetting part — adults are much more sophisticated than kids throwing tantrums. And they may well come back and harangue you again for the meds you said were inappropriate. The only way that true private practice may be better is that you can tell them you will not see them anymore due to their behavior, and it can be your decision as opposed to appealing to the management.

Let them.

The medical board won't care (at least in my state there has never been a doctor sanctioned for NOT prescribing controlled substances). If you live in a stricter state, just document why its not appropriate and if its something with a dangerous withdrawal (xanax 2mg qid, for example), offer referral to detox or a strict taper if you're OK with doing that.

You're a psychiatrist, Yelp/google reviews won't hurt you all that much - especially if you take insurance. For every patient that gets pissed off and leaves, there are 12 more waiting to take their place.

They can yell/whine/manipulate/argue all they want. If I as a lowly FP can weather that I should think that a psychiatrist would have no trouble on that score.

 

[Mad Jack]

The people you see who are Medicaid recipients . . . have they disclosed that? Maybe Texas is different than where I live. Where I am you can't take fee for service from Medicaid patients, which can put people in a jam. I don't want to say too much in case I am identifiable by things I've posted, but a friend of mine has taken a don't ask don't tell approach which has caused anxiety. Also it seems like some doctors are unaware in my area of this rule, especially when Medicaid is secondary. Some doctors think secondary status doesn't prevent them from seeing them, when from my reading of the law, it does. A friend of mine finally told their therapist because it had been a bubbling concern that it would come to light eventually which caused anxiety, but the therapist was willing to remain ignorant allowing my friend to continue paying cash for the service. There was also a federal rule change in 2014 that prescriptions by non-Medicaid providers cannot be covered by Medicaid. So even if you get to see a non-Medicaid doctor, it can be expensive for filling scripts. There is an exception for ORP providers, which to make a long story short, from my recollection is like dipping your toe into Medicaid but not being a full-fledged provider.

I thought this only applied to providers that were not opted out of Medicare/Medicaid. If you're opted out it's fine in my state.

 

[birchswing]

I thought this only applied to providers that were not opted out of Medicare/Medicaid. If you're opted out it's fine in my state.

Yeah I think it does vary state by state. In mine I've read the rules pretty carefully and even if you're not opted in, as soon as you see someone with Medicaid you're only supposed to take payment from Medicaid regardless, which means people can get turned away even if they want to pay out of pocket or even if they have a primary insurance the provider does accept. When I was researching it I came across some state (can't remember which) in which you could sign an agreement between the physician and patient regarding payment outside of Medicaid. But in my state that does not appear to be an option. I'm not sure how much it's enforced as a lot of people seem to have confusion about the law.

 

[sighchiatry]

EMR

I use Office Ally 24/7. I've been tempted to switch to DrChrono or Luminello. However, I'm sort of tied to OA because I do my own billing/claim submission and it's integrated with a good free clearinghouse (Office Ally). Add on features include e-prescribe (free), e-controlled substance rx ($100/year), appointment reminders ($30/mo), practice management/accounting module (free), integrated credit card processing (Worldpay).

Patient Portal

The integrated patient portal with Office Ally is called patiently. Here patients message me; during our first visit, I tell them this is the best way to communicate with me. So, most of my contact with patients comes through here. Very rarely do people call and leave a message. Patients can see my availability and schedule their own appointments. Again, very rarely do people call and try and make an appointment. Many of my therapy patients schedule in-session and my med-management patients will nicely fill in the gaps in my schedule every month or so. There's a preference given if you're coming in every week.

Text Reminders

Patients get a text message 48h before their appointment. They press "2" if they want to cancel. In the text, are the links to patient portal (if they want to re-schedule) and doxy.me (telepsychiatry). These reminders are automatically tied to the scheduled appointment in EMR. There is 0 risk of making a mistake.

Phone/Fax

I use a business version of google voice, which is covered by BAA (HIPAA compliant). If you pay for enterprise voice, it comes with a # for an auto-attendant and a direct line. When people call they are asked if they are an existing patient (taken to prompt if the matter is non-urgent --> voicemail or to be directly connected --> calls my phone), new patient (given directions to go to my website to request appt because of high call volume), crisis resources (--> forwarded to crisis center), forensic (-->forwarded to my cell), other (--> voicemail). The voicemails are transcribed and emailed to me. The downside, is that google voice calls will show my direct line or anonymous (people won't answer this). So, to fix, I use the doximity dialer. This lets you call anyone and display any # you like (for me, the auto-attendant/main #). I also use doximity free fax #.

Other software

I use google business apps (sheets, docs, sites, forms, drive, voice). These are covered by BAA, as I mentioned. On my website, there is a google form with which new patients request consultations, with screening questions. These go into a google sheet. I'm emailed when I get a new request.

Computer

I use a google pixelbook/chromebook which is a 2 in 1 with a pen. Again everything integrated with google.

Awesome. Thank you for sharing. Always appreciate and enjoy your input.

 

[meow1985]

EMR

I use Office Ally 24/7. I've been tempted to switch to DrChrono or Luminello. However, I'm sort of tied to OA because I do my own billing/claim submission and it's integrated with a good free clearinghouse (Office Ally). Add on features include e-prescribe (free), e-controlled substance rx ($100/year), appointment reminders ($30/mo), practice management/accounting module (free), integrated credit card processing (Worldpay).

Patient Portal

The integrated patient portal with Office Ally is called patiently. Here patients message me; during our first visit, I tell them this is the best way to communicate with me. So, most of my contact with patients comes through here. Very rarely do people call and leave a message. Patients can see my availability and schedule their own appointments. Again, very rarely do people call and try and make an appointment. Many of my therapy patients schedule in-session and my med-management patients will nicely fill in the gaps in my schedule every month or so. There's a preference given if you're coming in every week.

Text Reminders

Patients get a text message 48h before their appointment. They press "2" if they want to cancel. In the text, are the links to patient portal (if they want to re-schedule) and doxy.me (telepsychiatry). These reminders are automatically tied to the scheduled appointment in EMR. There is 0 risk of making a mistake.

Phone/Fax

I use a business version of google voice, which is covered by BAA (HIPAA compliant). If you pay for enterprise voice, it comes with a # for an auto-attendant and a direct line. When people call they are asked if they are an existing patient (taken to prompt if the matter is non-urgent --> voicemail or to be directly connected --> calls my phone), new patient (given directions to go to my website to request appt because of high call volume), crisis resources (--> forwarded to crisis center), forensic (-->forwarded to my cell), other (--> voicemail). The voicemails are transcribed and emailed to me. The downside, is that google voice calls will show my direct line or anonymous (people won't answer this). So, to fix, I use the doximity dialer. This lets you call anyone and display any # you like (for me, the auto-attendant/main #). I also use doximity free fax #.

Other software

I use google business apps (sheets, docs, sites, forms, drive, voice). These are covered by BAA, as I mentioned. On my website, there is a google form with which new patients request consultations, with screening questions. These go into a google sheet. I'm emailed when I get a new request.

Computer

I use a google pixelbook/chromebook which is a 2 in 1 with a pen. Again everything integrated with google.

Let them.

The medical board won't care (at least in my state there has never been a doctor sanctioned for NOT prescribing controlled substances). If you live in a stricter state, just document why its not appropriate and if its something with a dangerous withdrawal (xanax 2mg qid, for example), offer referral to detox or a strict taper if you're OK with doing that.

You're a psychiatrist, Yelp/google reviews won't hurt you all that much - especially if you take insurance. For every patient that gets pissed off and leaves, there are 12 more waiting to take their place.

They can yell/whine/manipulate/argue all they want. If I as a lowly FP can weather that I should think that a psychiatrist would have no trouble on that score.

I know. I’m just raising this point because OP wants to go into PP because and avoid IP because they are sensitive to patients’ hurtful statements. I was just pointing out that in PP it may just hurt more, while IP may not be so bad especially when you see it in context of patients being extremely ill and distressed.

 

[VA Hopeful Dr]

I know. I’m just raising this point because OP wants to go into PP because and avoid IP because they are sensitive to patients’ hurtful statements. I was just pointing out that in PP it may just hurt more, while IP may not be so bad especially when you see it in context of patients being extremely ill and distressed.

Ah, I missed that part. All fair points.

 

[keolu hills]

I am not sure where you got anything about people being illiterate and uneducated from, that's something you're bringing to the table.

It doesn't matter if someone is a Nobel Laureate, when you go into a situation where one of you is spilling their guts about sensitive details of their inner lives and the other is disclosing almost nothing, you have an asymmetrical relationship. That's even setting aside the fact that only one of you had a prescription pad or the fact that if you fire then you are going to fill their slot way faster than they are going to see a new psychiatrist. You are the one with the power in this situation.

Now, if you are emotionally involved to the extent they can hold you hostage via your anxiety or desire to be loved, well...you may not be the one with the power, but you are doing it wrong. If you think about how you can't control them and your reaction is not "yeah, I guess not, at the end of the day" but "oh god oh god oh god" you need to revisit how you are relating to your patients.

Clause, I really misunderstood your post. I am sorry for my rude post. Now I understand what you mean, and I agree with what you said here.

Again, my apologies for being rude.

 

[Jules A]

I know. I’m just raising this point because OP wants to go into PP because and avoid IP because they are sensitive to patients’ hurtful statements. I was just pointing out that in PP it may just hurt more, while IP may not be so bad especially when you see it in context of patients being extremely ill and distressed.

I agree that there has to be a more direct approach with PP patients who are upset about your recommendations as opposed to inpatient but I generally don't resort to "blame a system" because at the very least that shorts you the opportunity to learn to comfortably address these confrontations. A significant number of the patients I care for, that are not manic or psychotic, often have a shortage of people willing to challenge their flawed logic. I feel it is my job to briefly attempt to educate them on my opinion of the detriments as well as alternatives such as the benefit of structured therapy and non-pharm coping skills. They get a very small window to speak their piece and then we are finished. I generally say something like "I understand you feel XYZ is the only thing that helps you but from where I'm sitting it appears as if you are still suffering and I believe we could try a different, safer approach. As you pointed out you can definitely find someone who is willing to prescribe XYZ if you decide that I'm not a good fit for you at this time". And thats it. I will not allow my time to be wasted by someone tantruming because they aren't able to dictate what I prescribe. It is uncomfortable but you will get better at it and desensitized to some extent. The payoff for me is the few who consider working with me and the few who later return and are eventually appreciative of my candor and alternative strategy as that is where the true growth happens for them.

 

[whopper]

Highly varies.

Depends on what types of patients you take in. You have some ability to prune them. While any doctor can kick out any patient (albeit possibly unethically), this can also affect your patient population.

I will not tolerate too many cluster B hijinks from patients if they don't have the humility to take responsibility for them. E.g. some punk narcissistic came into the office and got mad at us because we couldn't get in touch with him on the phone despite that he knowingly changed his phone number and didn't tell us the new phone number. After telling him politely 3x that this was the reason why, he retorted that because I'm an educated professional I should've figured a way to get his phone number despite that he didn't give it to us.

After the 3rd time I told him very politely that he was terminated from my practice, and that perhaps he should find a doctor that has the expertise in finding people's new phone numbers despite that they weren't told the new number.

So what ended up happening was after about 1-2 years of this the over-the-top drama cluster B patients were cut down. Of course I am completely willing and wanting to treat people with cluster B disorders who want treatment for them. I also consulted with 2 DBT therapists who even told me my approach was right because the guy above needs to be held accountable for his obviously unreasonable actions.

So bottom line a lot of it can also be up to you. Medicaid patients tend to bring in certain types, as does completely private pay, as does insurance.

Edit, added in later: My amount of troublesome BS significantly went down after I pruned down troublesome patients. What I mean by troublesome isn't that they're sick, it's by that they were irresponsible and not holding up their responsibilities as a patient. E.g like the patient above, or a patient asks me for more Adderall, why? Cause it worked so well for her, and she really has ADHD, that she gave some to her dad who she believes also has ADHD, and yes I already told her beforehand it's a controlled substance and she can't do stuff like this. So I politely told her she's breaking her treatment responsibilities and she should get her father to see his own doctor because sharing prescribed meds is illegal, that I'd be willing to continue treating her but she needed to follow the rules, etc, and she, like an immature brat, told me that as the customer she's always right, yada yada yada, and that I better do what she said "or else."

I politely told her, well then, find a doctor who agrees with your philosophy on doctor patient relationships. I cannot follow it because it's against the law and I follow the law. "I'll be sending you a termination letter in the mail. Good luck."

First year of private practice I was literally terminating about 3 patients a month.