What's Your Niche? How Do I Make My Own Niche?

[hippopotamusoath]

There's been some fantastic recent discussion on setting up a private practice. There has also been some good discussion on the future of psychiatry, and this question speaks to both subjects.

In the future of psychiatry thread, one commenter was a little bit perseverative about our field needing to move into a more "prestigious" direction. I'm not trying to re-open a can of worms, but what I took from that commenter was that an individual psychiatrist can insulate themselves from some of the unfavorable forces around us by moving up in terms of technical prowess, skill, exclusivity, etc.

Basically, if I start a private practice, it seems like it's a good idea to develop a niche (OCD with combined meds and ERP, something like that), and try to get as good as possible at it. For what it's worth, this question is more intended for those of us who did not do a fellowship, since that would indicate a niche interest already...

So, for those who are known for their niche--what's your niche? How did you develop it? Was it worth it? Do you actively market your practice that way, or have you come to be known for your expertise passively, as you've presumably done good work over the years? What sort of post-residency training have you sought to support this? Did it open up more doors for you or pigeon-hole you in a negative way? If you run a cash practice, did it drive referrals, since you are offering value to patients--something they simply cannot get anywhere else?

Thanks for any thoughts, kind of rambling but hopefully my point gets across.

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[dl2dp2]

You are thinking too hard and not quite understanding what I meant. As a *field*, yes, people have been working on packaging so the field is more prestigious, which I think is necessary and important. This is in the context of comments of people complaining of systemic issues of lack of support/funding for social work, other structural issues, the direction of the field in advocacy and research, whether practicing "below your license" is desirable and/or necessary, etc.

For individual practices, not everyone benefits from prestige thinking. You might. You might not. Not everyone is an LV bag, and if you are not and you try too hard to become one, you'll fail and be miserable. Plenty of very successful practices don't do any prestige niche work. Most importantly, LV bags don't sell well everywhere. You need a product-market match. Blindly going after prestige for its own sake is not a wise business decision.

The most important thing about private practice is cash flow. Get patients in the door in whatever way you can and try a bunch of things until something sticks. In effect, prestige = high demand x high price. The first step is to figure out your demand--you adjust your price based on your demand, then change your product incrementally to attract the segment that can afford the high price. Then after a while, you'll notice that you organically have the prestige product.

 

[TexasPhysician]

I think entrepreneurial skills or joining a physician only practice is the best way to insulate yourself.

You can have any number of amazing specialties, but most institutions consider you based on profit margin alone.

 

[Merovinge]

In the medium to long term the best niche for private practice is providing high quality care. If that looks like meds +psychotherapy, extensive chart/history review to clarify meds/diagnosis, strong networking with good therapists and php/iop programs, use of metrics/technology, or anything else that makes sense and is evidenced based or at a minimum strongly expert consensus.

Think about what you think about when choosing to refer patients. Typically availability is number 1 and quality is the 1a or 2, confidence and kindness might come down as #3. When you start you will automatically have availability so you can really drill into quality. Personality is tough to change at this point but certainly put your best foot forward by taking good care of your own physical/mental health.

 

[Sushirolls]

I started out wanting to do niche, by becoming the go to referral place for TMS, ECT, IV ketamine, and expand to bring on more Psychiatrists and a few CBT focused psychologists.

I did hypnotherapy as my focus for therapy development. I've done some cases, its fun, but nothing I've really stuck with. Covid sort of ended it and I haven't resumed it.

I am now the opposite of niche. Middle of the road med check, taking most insurance. No medicaid, sprinkle of medicare. Part time assistant. Part time hours. I don't even do any benzos. I'll taper people off. I don't do ambien. I UDS test my stimulant patients. I counsel against any cannabis.

What I do that's different, but not exactly niche: I respond to people timely with my Luminello EMR. I discuss diagnoses in the chart at first visit. I allow patients to schedule themselves after first visit. I do addiction work, i.e. I don't punt SUDs and have no problem with OUD. I call back PCPs or therapists who call me. Ultimately, I am here, and available, and I'm the warm body filling the chair. I am in a rural area where things are not saturated.

I moved from an area where it was saturated with ARNPs and Big Box shops. It was slow growth. I had a positive reputation in the Big Box shops and got more complex referrals. But that wasn't enough to even be considered a niche. Fastforward to today, I'm okay being the plain vanilla psychiatrist.

 

[forchinet121]

I started out wanting to do niche, by becoming the go to referral place for TMS, ECT, IV ketamine, and expand to bring on more Psychiatrists and a few CBT focused psychologists.

I did hypnotherapy as my focus for therapy development. I've done some cases, its fun, but nothing I've really stuck with. Covid sort of ended it and I haven't resumed it.

I am now the opposite of niche. Middle of the road med check, taking most insurance. No medicaid, sprinkle of medicare. Part time assistant. Part time hours. I don't even do any benzos. I'll taper people off. I don't do ambien. I UDS test my stimulant patients. I counsel against any cannabis.

What I do that's different, but not exactly niche: I respond to people timely with my Luminello EMR. I discuss diagnoses in the chart at first visit. I allow patients to schedule themselves after first visit. I do addiction work, i.e. I don't punt SUDs and have no problem with OUD. I call back PCPs or therapists who call me. Ultimately, I am here, and available, and I'm the warm body filling the chair. I am in a rural area where things are saturated.

I moved from an area where it was saturated with ARNPs and Big Box shops. It was slow growth. I had a positive reputation in the Big Box shops and got more complex referrals. But that wasn't enough to even be considered a niche. Fastforward to today, I'm okay being the plain vanilla psychiatrist.

You are rural but saturated? That’s quite unfortunate I thought the point of rural was that there would be a ton of demand and no supply

 

[Sushirolls]

sorry, fixed that post, Not saturated in rural location

 

[Sushirolls]

There's probably room for a psychiatrist to put themselves out there to connect with the NRA and other gun rights groups to counter the left leaning media slant against gun rights and the perpetuation of "gun violence" labels. I.e. a media consultant for news networks at times.

 

[ElanaMD]

I am super excited to answer this question for you.

In my opinion (and reasonable people may disagree), the answers are yes, it's good to develop a niche and become excellent at it, no you don't need to do a fellowship in your niche, although it's useful to do advanced trainings, and no, it won't pigeon hole you, because in a cash-practice you can always shift directions based on what you enjoy doing and you also won't JUST be seeing a narrow population of patients in your practice, even if you specialize.

I don't think every psychiatrist needs to have a narrow focus -- I know someone on the thread earlier mentioned being more of a bread-and-butter psychiatrist accepting insurance. We need all kinds of psychiatrists because there are all kinds of patients. So I'm not saying not everyone needs to do what I recommend. If you do, though, it will be rewarding and a lot of fun.

People often use the term "niche" to refer to a diagnosis or specialty (e.g. "my niche is anxiety disorders") but a niche is actually a group of people, so for example, "women 25-45 living in Los Angeles with generalized anxiety." The difference becomes crucial when you are marketing, because a group of people you can find and market to, especially if you think about what other services this group of people use or places they go. A group of people also has multiple problems, not just one. Maybe you start off solving one of their problems, but then you can expand and solve multiple of their problems.

So yes, it's useful to define what niche(s) you want to specialize in, but the more important thing is to define your UNIQUE SELLING PROPOSITION, or USP. This is a general business term, I didn't make it up. A USP is your "special sauce" that will make a patient want to see you as opposed to a different provider. It's the unique value you offer to your patients that prevents you from being a commodity. It can encompass your unique clinical skills, BUT ALSO YOUR PERSONALITY AND LIVED EXPERIENCE. One of the best ways to specialize in a practice is to take what you know well because you've lived it, and translate it into your clinical work.

Let me give use myself as an example. In the home page, "above the fold" (prior to scrolling down) you can see this text:

Ancient Wisdom Meets Modern Medicine
Hi, I’m Elana Miller MD, and I believe that Medicine = Science + Heart.
I’m a psychiatrist passionate about integrating Western medicine, Eastern wisdom, and holistic approaches to help people live fuller and happier lives.
I’m also a cancer survivor who teaches the resilience of the human spirit and the power of love.

It's only a few sentences but it pretty well sums up something unique about who I am and the type of care I offer. It includes a unique area of medicine I've specialized in (integrative psychiatry) but also aspects of my lived experience that have affected how I practice medicine (being a cancer survivor).

I was diagnosed with T-Cell ALL at 31 in my 4th year of residency. I did a three year chemotherapy regimen (yes, THREE YEARS), then was healthy for two years, and then relapsed again at 36 and had a stem cell transplant. It was horrible and traumatic. And yet, this experience has become a major thing that attracts patients to me. This wasn't intentional at all. I wrote a blog about my cancer experience while it was happening, not sure if I would ever practice medicine again or even survive it. But I did, and then I started a practice, and I was hesitant at first knowing I had put out all of these personal essays about myself. However it ended up really helping my practice grow and patients mention this to me all the time when their telling me what led them to reach out.

Patients want a psychiatrist who is skilled and competent, but it also human. They want to see someone who they think will "get" them.

So a niche/USP can be intentional, but it also can be something you fall into because of circumstance.

This is just a single example. I also coach psychiatrists on private practice and here are some of the USPs of the clinicians I've worked with:

• Psychiatrist who traveled to Peru every summer to study (and use) traditional psychedelic medicine who now does psychedelic integration therapy
• Psychiatrist who was a nerd in high school and addicted to video games who went through a self-transformation and now works with adolescent and young adult male gamers to improve their mental health as well as working on grooming, fitness, dating, etc
• Psychiatrist who spent years doing advocacy on climate change and focuses on eco-distress in his practice

You don't have to ONLY see patients who fit into your area of specialty -- half of your practice will probably end up being bread and butter psych. You just want to be the GO TO PERSON for your niche. This will absolutely drive referrals because you will be top-of-mind for potential referral sources when they come across a patient in your niche.

As a side note, I didn't see the thread on the future of psychiatry, but I will say I feel my career is future proofed because of the way I've built my practice and the business platform I've created. I specifically went into psychiatry (as opposed to surgery, which is what I went to medical school to do and thought I was going to do until the end of 3rd year) because of the opportunities to branch out in creative and entrepreneurial ways. It's not that there aren't problems in private practice -- it's just that any problems you have will be under your control to solve (as opposed to working in a bureaucratic system). I love my work, and it's really rewarding to get to feel like you are having a significantly positive impact on your patients' lives.

Tr;dl: Yes, you should niche/specialize. Lean into your specific clinical interests as well as unique lived experience. Become excellent at what you do. Make sure others know what you specialize in so they will send you referrals. Own your own business and your career will be future-proofed.

 

[Sushirolls]

I was taught in residency to keep our lived experiences to ourselves.

I'm sorry you've had your battle with cancer, I'm glad you've triumphed.

I see people posting on their websites their personal experiences it harkens to poor taste, unprofessional and resonates on par with what is often seen by ARNPs.

Our job is to check ourselves at that door and be unbiased to service as many patients as possible. To not wave our tribal identity flags. Where one person sees a connection, others will see a wall.

Larger Academic centers of Psychiatry services embed in Oncology departments and these psychiatrists may or may not have done C/L fellowships. Should they have had an oncological diagnosis to better connect? Should every man stay away from women's health because of a lack of ability to advertise shared experience? Should only a person who is LGBTQ advertise to this population?

My doctors; I look at their training.

Even if I seen things that positively resonate with me, my politics, my hobbies, my 'tribe', whatever, I still won't select them out specifically but avoid them. Why does that matter? Why are they putting that out there? I want a doctor who will be professional, do their job and give me the same quality care they give everyone else - whether I am a Sushiroll or Seaweed salad.

Does a Sleep Medicine doctor need to start saying I have OSA? Narcolepsy? Insomnia? Do the general surgeons need say they've had a hernia and are the better hernia specialist?

Putting too much emphasis on ones experiences can be bad. Previous location, Psych ARNP on inpatient unit told several of my patients, 'I have autism, I know what autism is, you have autism.'

Am I wrong? Has something changed in residency the past few years where we are now supposed to disclose things about ourselves? Am I now an outdated dinosaur who didn't get the memo?

 

[ElanaMD]

I was taught in residency to keep our lived experiences to ourselves.

I'm sorry you've had your battle with cancer, I'm glad you've triumphed.

I see people posting on their websites their personal experiences it harkens to poor taste, unprofessional and resonates on par with what is often seen by ARNPs.

Our job is to check ourselves at that door and be unbiased to service as many patients as possible. To not wave our tribal identity flags. Where one person sees a connection, others will see a wall.

Larger Academic centers of Psychiatry services embed in Oncology departments and these psychiatrists may or may not have done C/L fellowships. Should they have had an oncological diagnosis to better connect? Should every man stay away from women's health because of a lack of ability to advertise shared experience? Should only a person who is LGBTQ advertise to this population?

My doctors; I look at their training.

Even if I seen things that positively resonate with me, my politics, my hobbies, my 'tribe', whatever, I still won't select them out specifically but avoid them. Why does that matter? Why are they putting that out there? I want a doctor who will be professional, do their job and give me the same quality care they give everyone else - whether I am a Sushiroll or Seaweed salad.

Does a Sleep Medicine doctor need to start saying I have OSA? Narcolepsy? Insomnia? Do the general surgeons need say they've had a hernia and are the better hernia specialist?

Putting too much emphasis on ones experiences can be bad. Previous location, Psych ARNP on inpatient unit told several of my patients, 'I have autism, I know what autism is, you have autism.'

Am I wrong? Has something changed in residency the past few years where we are now supposed to disclose things about ourselves? Am I now an outdated dinosaur who didn't get the memo?

Hi Sushiroll, I think we can agree to disagree respectfully. I very much disagree with the premise that we can't lean into lived experience in our clinical care. Of course I'm not saying that you NEED to have a certain lived experience to treat patients effectively. I'm just saying the traditional view (that I learned in residency, too) that lived experience will automatically lead to unchecked countertransference is misguided.

I had people tell me I shouldn't specialize in treating cancer patients because it would hit "too close to home" and that "sometimes people with cancer will die and that can be hard" -- as if I didn't know that 100 times better than they did. Who would be better at treating cancer patients than a trained psychiatrist who has also lived through it? It was honestly extremely condescending to be lectured to by people assuming I would be unable to manage possibility of projection/countertransference. And ultimately, they were wrong.

Are you a dinosaur? I have no idea. Are you referencing being old? I might argue that your ideas are old fashioned. Age doesn't guarantee wisdom, nor does youth preclude it. A wise perspective when it comes to self-disclosure comes from balance, being able to understand nuance, and appreciating ones internal biases and potential projections. I don't think it was necessary to put down ARNPs in making your point, or to imply I'm waiving a "tribal identity flag" or otherwise being unprofessional or operating in poor taste when I'm making my point or sharing my perspectives. I don't think it's ever necessary to put down anyone to make any point, which seems to be a concept that's lost on this forum sometimes.

People can read your perspective, read mine, and decide whom they agree with. I would argue that ultimately none of our opinions matters anyway -- assuming we are all being ethical and providing good care, it's our patients who get to decide what's too much, and what's just enough.

 

[futureapppsy2]

I was taught in residency to keep our lived experiences to ourselves.

I'm sorry you've had your battle with cancer, I'm glad you've triumphed.

I see people posting on their websites their personal experiences it harkens to poor taste, unprofessional and resonates on par with what is often seen by ARNPs.

Our job is to check ourselves at that door and be unbiased to service as many patients as possible. To not wave our tribal identity flags. Where one person sees a connection, others will see a wall.

Larger Academic centers of Psychiatry services embed in Oncology departments and these psychiatrists may or may not have done C/L fellowships. Should they have had an oncological diagnosis to better connect? Should every man stay away from women's health because of a lack of ability to advertise shared experience? Should only a person who is LGBTQ advertise to this population?

My doctors; I look at their training.

Even if I seen things that positively resonate with me, my politics, my hobbies, my 'tribe', whatever, I still won't select them out specifically but avoid them. Why does that matter? Why are they putting that out there? I want a doctor who will be professional, do their job and give me the same quality care they give everyone else - whether I am a Sushiroll or Seaweed salad.

Does a Sleep Medicine doctor need to start saying I have OSA? Narcolepsy? Insomnia? Do the general surgeons need say they've had a hernia and are the better hernia specialist?

Putting too much emphasis on ones experiences can be bad. Previous location, Psych ARNP on inpatient unit told several of my patients, 'I have autism, I know what autism is, you have autism.'

Am I wrong? Has something changed in residency the past few years where we are now supposed to disclose things about ourselves? Am I now an outdated dinosaur who didn't get the memo?

In psychology, I was generally taught (and teach) that self-disclosure should be used judiciously and only when it's for the benefit of the patient, not to make the therapist feel better. There's always a risk of the patient feeling like they have to take care of the therapist or can't talk about certain things with them after self-disclosure or the patient or therapist assuming that the other person had the same experience they did (I always tell my students "You don't know how *they* feel, you only know how *you* felt in a similar situation, and it can be dangerous to assume those are the same"), which are real risks. On the other hand, careful self-disclosure can be super helpful in building rapport--my mom's cardiologist, for example, has disclosed that he's dealt with similar symptomatic PVCs as her, for example, and I think it does build trust that he's not just going to blow her off. Of course, this is much less important than practicing good medicine, and that should always come first, but I don't think self-disclosure is inherently wrong, if it's done carefully and with a clinical purpose.

 

[hamstergang]

I was taught in residency to keep our lived experiences to ourselves.

Even if I seen things that positively resonate with me, my politics, my hobbies, my 'tribe', whatever, I still won't select them out specifically but avoid them. Why does that matter? Why are they putting that out there? I want a doctor who will be professional, do their job and give me the same quality care they give everyone else - whether I am a Sushiroll or Seaweed salad.

I personally put very little if any of my personal life out there to patients, so I certainly agree that you don't need to match up with them to do well. But didn't you previously say that many patients come to you and trust you because you are Republican/conservative like them?

 

[clausewitz2]

I am super excited to answer this question for you.

In my opinion (and reasonable people may disagree), the answers are yes, it's good to develop a niche and become excellent at it, no you don't need to do a fellowship in your niche, although it's useful to do advanced trainings, and no, it won't pigeon hole you, because in a cash-practice you can always shift directions based on what you enjoy doing and you also won't JUST be seeing a narrow population of patients in your practice, even if you specialize.

I don't think every psychiatrist needs to have a narrow focus -- I know someone on the thread earlier mentioned being more of a bread-and-butter psychiatrist accepting insurance. We need all kinds of psychiatrists because there are all kinds of patients. So I'm not saying not everyone needs to do what I recommend. If you do, though, it will be rewarding and a lot of fun.

People often use the term "niche" to refer to a diagnosis or specialty (e.g. "my niche is anxiety disorders") but a niche is actually a group of people, so for example, "women 25-45 living in Los Angeles with generalized anxiety." The difference becomes crucial when you are marketing, because a group of people you can find and market to, especially if you think about what other services this group of people use or places they go. A group of people also has multiple problems, not just one. Maybe you start off solving one of their problems, but then you can expand and solve multiple of their problems.

So yes, it's useful to define what niche(s) you want to specialize in, but the more important thing is to define your UNIQUE SELLING PROPOSITION, or USP. This is a general business term, I didn't make it up. A USP is your "special sauce" that will make a patient want to see you as opposed to a different provider. It's the unique value you offer to your patients that prevents you from being a commodity. It can encompass your unique clinical skills, BUT ALSO YOUR PERSONALITY AND LIVED EXPERIENCE. One of the best ways to specialize in a practice is to take what you know well because you've lived it, and translate it into your clinical work.

Let me give use myself as an example. In the home page, "above the fold" (prior to scrolling down) you can see this text:

Ancient Wisdom Meets Modern Medicine
Hi, I’m Elana Miller MD, and I believe that Medicine = Science + Heart.
I’m a psychiatrist passionate about integrating Western medicine, Eastern wisdom, and holistic approaches to help people live fuller and happier lives.
I’m also a cancer survivor who teaches the resilience of the human spirit and the power of love.

It's only a few sentences but it pretty well sums up something unique about who I am and the type of care I offer. It includes a unique area of medicine I've specialized in (integrative psychiatry) but also aspects of my lived experience that have affected how I practice medicine (being a cancer survivor).

I was diagnosed with T-Cell ALL at 31 in my 4th year of residency. I did a three year chemotherapy regimen (yes, THREE YEARS), then was healthy for two years, and then relapsed again at 36 and had a stem cell transplant. It was horrible and traumatic. And yet, this experience has become a major thing that attracts patients to me. This wasn't intentional at all. I wrote a blog about my cancer experience while it was happening, not sure if I would ever practice medicine again or even survive it. But I did, and then I started a practice, and I was hesitant at first knowing I had put out all of these personal essays about myself. However it ended up really helping my practice grow and patients mention this to me all the time when their telling me what led them to reach out.

Patients want a psychiatrist who is skilled and competent, but it also human. They want to see someone who they think will "get" them.

So a niche/USP can be intentional, but it also can be something you fall into because of circumstance.

This is just a single example. I also coach psychiatrists on private practice and here are some of the USPs of the clinicians I've worked with:

• Psychiatrist who traveled to Peru every summer to study (and use) traditional psychedelic medicine who now does psychedelic integration therapy
• Psychiatrist who was a nerd in high school and addicted to video games who went through a self-transformation and now works with adolescent and young adult male gamers to improve their mental health as well as working on grooming, fitness, dating, etc
• Psychiatrist who spent years doing advocacy on climate change and focuses on eco-distress in his practice

You don't have to ONLY see patients who fit into your area of specialty -- half of your practice will probably end up being bread and butter psych. You just want to be the GO TO PERSON for your niche. This will absolutely drive referrals because you will be top-of-mind for potential referral sources when they come across a patient in your niche.

As a side note, I didn't see the thread on the future of psychiatry, but I will say I feel my career is future proofed because of the way I've built my practice and the business platform I've created. I specifically went into psychiatry (as opposed to surgery, which is what I went to medical school to do and thought I was going to do until the end of 3rd year) because of the opportunities to branch out in creative and entrepreneurial ways. It's not that there aren't problems in private practice -- it's just that any problems you have will be under your control to solve (as opposed to working in a bureaucratic system). I love my work, and it's really rewarding to get to feel like you are having a significantly positive impact on your patients' lives.

Tr;dl: Yes, you should niche/specialize. Lean into your specific clinical interests as well as unique lived experience. Become excellent at what you do. Make sure others know what you specialize in so they will send you referrals. Own your own business and your career will be future-proofed.

Was this Alok Kanojia or are other people also doing his schtick?


This post is fantastic. Speaking as someone who drifted into a niche in similarly not-entirely-intentional way, advice I can give is to be yourself in as genuine way as possible in interacting with patients, at least within the therapeutic framework that you choose to implement. Doesn't mean you need to do huge amounts of personal disclosure but it's important to feel like a human if people are going to want to keep coming back. People like people, less so medication vending machines. I tend to think if you go out there and do the outpatient work in private practice and are very much yourself, after 6 months to a year you will be able to look at your caseload and identify the people who appear to be drawn to your style.

What I'm saying is, use your personality, experiences, approach, manner etc as a filter. It is going to lead you to your niche if you pay attention to the results.

EDIT: I guess what I'm saying is that since PP psychiatry is very much about building an ongoing (clinical) relationship with patients in a way few specialties in medicine are (good PCPs practicing concierge-ish or at least lower volume medicine come to mind), putting yourself in to your work with patients does mean you have to show up in a way that feels authentic. This doesn't mean disclosing willy-nilly, or even necessarily much at all, but I would argue that it is probably important to occasionally share your actual reaction to something or speak in a way that does not always sound like you are reading out of a therapy manual.

Unless of course you are someone who is just super formal and reserved by nature! If this is true, you do not want to try too hard to be otherwise, I'd argue, because it's going to come across as clowning if you don't have practice at it. If you are just super formal and reserved, it just means you are going to attract patients on-goingly who are reassured by someone who is. very. controlled. and. measured.

No one's asking you to be woke, @Sushirolls , just to be yourself.

 

[Celexa]

I was taught in residency to keep our lived experiences to ourselves.

I'm sorry you've had your battle with cancer, I'm glad you've triumphed.

I see people posting on their websites their personal experiences it harkens to poor taste, unprofessional and resonates on par with what is often seen by ARNPs.

Our job is to check ourselves at that door and be unbiased to service as many patients as possible. To not wave our tribal identity flags. Where one person sees a connection, others will see a wall.

Larger Academic centers of Psychiatry services embed in Oncology departments and these psychiatrists may or may not have done C/L fellowships. Should they have had an oncological diagnosis to better connect? Should every man stay away from women's health because of a lack of ability to advertise shared experience? Should only a person who is LGBTQ advertise to this population?

My doctors; I look at their training.

Even if I seen things that positively resonate with me, my politics, my hobbies, my 'tribe', whatever, I still won't select them out specifically but avoid them. Why does that matter? Why are they putting that out there? I want a doctor who will be professional, do their job and give me the same quality care they give everyone else - whether I am a Sushiroll or Seaweed salad.

Does a Sleep Medicine doctor need to start saying I have OSA? Narcolepsy? Insomnia? Do the general surgeons need say they've had a hernia and are the better hernia specialist?

Putting too much emphasis on ones experiences can be bad. Previous location, Psych ARNP on inpatient unit told several of my patients, 'I have autism, I know what autism is, you have autism.'

Am I wrong? Has something changed in residency the past few years where we are now supposed to disclose things about ourselves? Am I now an outdated dinosaur who didn't get the memo?

I'm both at the start of my career and definitely at a different point of the political spectrum than you, and I agree.

I do agree with having a marketing strategy and being thoughtful about what patients you want to work with, but have seen enough misdiagnosis or suboptimal care due to a provider overidentifying with their patients and assuming they know what is going on instead of taking a neutral position and investigating to be very wary. I share exceedingly little. My patients learn I care about them and am working to understanding their problems by how I interact with them, not anything they know about me personally.

I don't think psychiatrists starting out need to worry too much about a niche to be successful. Maybe they need to think about it if there are clear patient populations they do or don't want to work with. But sadly, I am coming to the conclusion more and more that being responsive to patients regarding basic logistics and delivering thoughtful care ARE a niche in mental health. It's definitely not the norm!

 

[clausewitz2]

I'm both at the start of my career and definitely at a different point of the political spectrum than you, and I agree.

I do agree with having a marketing strategy and being thoughtful about what patients you want to work with, but have seen enough misdiagnosis or suboptimal care due to a provider overidentifying with their patients and assuming they know what is going on instead of taking a neutral position and investigating to be very wary. I share exceedingly little. My patients learn I care about them and am working to understanding their problems by how I interact with them, not anything they know about me personally.

However, I suspect the patients that stick with you will be doing so in significant part due to your personality and implicit worldview. I think your lived experiences can have a major impact on these things without you ever disclosing anything.

It is also the case that the particular turns of phrase you use or topics you appear to be familiar with when mentioned can be surprisingly specific shibboleths signaling your membership in or affinity with a particular social group. Any sociolinguist would tell you this is going to happen whether you mean it to nor not.

My family is from a part of the world with fairly distinctive speech patterns very different from where I am currently living. When I work with patients who happen to be from that part of the world, without even meaning to I start sounding a lot more like them because of that exact lived experience. Guess what? I have a weirdly high number of people from that part of the world consistently established on my caseload. I don't think this is a coincidence.

I don't think psychiatrists starting out need to worry too much about a niche to be successful. Maybe they need to think about it if there are clear patient populations they do or don't want to work with. But sadly, I am coming to the conclusion more and more that being responsive to patients regarding basic logistics and delivering thoughtful care ARE a niche in mental health. It's definitely not the norm!

Depressingly true.

 

[Sushirolls]

I personally put very little if any of my personal life out there to patients, so I certainly agree that you don't need to match up with them to do well. But didn't you previously say that many patients come to you and trust you because you are Republican/conservative like them?

No. Absolutely not. I at no point divulge my politics to patients be it Republican, Conservative, Liberal, Democratic, libertarian, etc.
Not once, never. Nor will I. It has no place in the office. Patients go on their rants in a Trump Derangement Syndrome fashion - I listen, I acknowledge their concerns and fears. Once, maybe twice I've had patients make more notable jabs at democrats - I don't engage, I don't confer or feed into it. I supportively listen. I maintain my affect to not divulge my true beliefs - because those won't help the patient. To @clausewitz2 point, I strive to minimize any linguistic disclosures to identify me with any category. But verbiage and lexicon are hard to mask and still can lead to conclusions.

Very rarely, very rarely, have I responded to topics of hunting or fishing or guns that might possibly be enough for people to extrapolate and raise suspicion of dialing in my politics/belief/culture. It was these people that opened up more. Contextually rapport was already present, they are already established patients. But the amount was minor enough to not be full on discovery/disclosure. Oh, you're going fishing for Salmon at XYZ, are you going to bank fish at ABC or work the hog lines in the river? How does this doc know 'hog line' or the name of that fishing spot? Or how does this doc know the opening day of Bear season?

I've talked chickens with folks because that is non-partisan. You have people with large meat flocks and you have people in suburbs with backyard flocks less than 5 that typically lean left.

Let's consider the converse. I lean into this whole notion of one's life experiences being advertised. I start putting up Elk heads, White Tail shoulder mounts, put up a nice Black Bear rug in full sprawl on the wall. Heck I'd go get me a few wolves, have their hides draped over the patient chairs. A few fully functional guns on the wall in display, too. I'd have a real wood, open fire place I keep stoked the whole day, even get up during patient encounters to put a new log on. Have signs that say pipe tobacco smoke okay - but no vapes, nor cannabis, nor cigarettes. Giant banner artistically glorifying the beauty of the 2nd amendment as an art piece. Have a deposit section for long rifles and hand guns "place your carry weapons here" in the waiting room. Openly post on my website, "out of office, hunting season, be back in 1 week." Doing so would possibly improve the odds that a like minded population seeks out care, but it would alienate a lot of people. I don't need to loudspeaker who I am to develop rapport with patients. They like me and stick with me because they sense I care, show I care in my actions and help them achieve their goals. I have the usual full spectrum transgender population, social activists, heck politicians that hold oppositive views from me, etc, etc

Going back to @ElanaMD post above [Thank you for being willing to put yourself and your identity out there on a social media platform like this, it is a big leap to openly cast yourself into the internet depths [applause and feelings of respect for that, truly]] she has listed in her description certain buzz words that culturally have a high percentage overlap with liberals/democrats
Ancient Wisdom
Eastern Wisdom
Holistic Approaches
Power of love
Those buzz words when read by conservative people immediately signify 'this is a liberal' or very high odds that they are, and they won't reach out to this person. I believe Elana is perfectly and fully capable of providing quality care to all political spectrums, but that is a waving of our emerging tribal flags and turns people away. If a person really believes in the power of love? Why must it be proselytized? Why can't it simply be a way of life displayed by ones actions? However, Elana could just be playing the game, like a true baller in her tough metro, and knowing her local population demographics want that and resonate with it and if she wants to compete in her area, she has to. Which brings up a concern I have, is if this notion spreads, we might all have to start playing towards this and posting up things to entice patients. I could just as easily present as a chameleon and feign being XYZ based upon what's more economical in my area of practice - if people want sushi, I'll serve them sushi. As a conservative/libertarian spectrum people have to do, to simply get through the American higher education system. But why? There is beauty in being neutral, apolitical, and just professional.

I'm also seeing more in various masters level therapist websites "Christian based care." What does that even mean? Do you just cite Job every appointment? This just pushes away muslims, hindus, sihks, jains, taoists, buddhists, etc.

 

[TexasPhysician]

No. Absolutely not. I at no point divulge my politics to patients be it Republican, Conservative, Liberal, Democratic, libertarian, etc.
Not once, never. Nor will I. It has no place in the office. Patients go on their rants in a Trump Derangement Syndrome fashion - I listen, I acknowledge their concerns and fears. Once, maybe twice I've had patients make more notable jabs at democrats - I don't engage, I don't confer or feed into it. I supportively listen. I maintain my affect to not divulge my true beliefs - because those won't help the patient. To @clausewitz2 point, I strive to minimize any linguistic disclosures to identify me with any category. But verbiage and lexicon are hard to mask and still can lead to conclusions.

Very rarely, very rarely, have I responded to topics of hunting or fishing or guns that might possibly be enough for people to extrapolate and raise suspicion of dialing in my politics/belief/culture. It was these people that opened up more. Contextually rapport was already present, they are already established patients. But the amount was minor enough to not be full on discovery/disclosure. Oh, you're going fishing for Salmon at XYZ, are you going to bank fish at ABC or work the hog lines in the river? How does this doc know 'hog line' or the name of that fishing spot? Or how does this doc know the opening day of Bear season?

I've talked chickens with folks because that is non-partisan. You have people with large meat flocks and you have people in suburbs with backyard flocks less than 5 that typically lean left.

Let's consider the converse. I lean into this whole notion of one's life experiences being advertised. I start putting up Elk heads, White Tail shoulder mounts, put up a nice Black Bear rug in full sprawl on the wall. Heck I'd go get me a few wolves, have their hides draped over the patient chairs. A few fully functional guns on the wall in display, too. I'd have a real wood, open fire place I keep stoked the whole day, even get up during patient encounters to put a new log on. Have signs that say pipe tobacco smoke okay - but no vapes, nor cannabis, nor cigarettes. Giant banner artistically glorifying the beauty of the 2nd amendment as an art piece. Have a deposit section for long rifles and hand guns "place your carry weapons here" in the waiting room. Openly post on my website, "out of office, hunting season, be back in 1 week." Doing so would possibly improve the odds that a like minded population seeks out care, but it would alienate a lot of people. I don't need to loudspeaker who I am to develop rapport with patients. They like me and stick with me because they sense I care, show I care in my actions and help them achieve their goals. I have the usual full spectrum transgender population, social activists, heck politicians that hold oppositive views from me, etc, etc

Going back to @ElanaMD post above [Thank you for being willing to put yourself and your identity out there on a social media platform like this, it is a big leap to openly cast yourself into the internet depths [applause and feelings of respect for that, truly]] she has listed in her description certain buzz words that culturally have a high percentage overlap with liberals/democrats
Ancient Wisdom
Eastern Wisdom
Holistic Approaches
Power of love
Those buzz words when read by conservative people immediately signify 'this is a liberal' or very high odds that they are, and they won't reach out to this person. I believe Elana is perfectly and fully capable of providing quality care to all political spectrums, but that is a waving of our emerging tribal flags and turns people away. If a person really believes in the power of love? Why must it be proselytized? Why can't it simply be a way of life displayed by ones actions? However, Elana could just be playing the game, like a true baller in her tough metro, and knowing her local population demographics want that and resonate with it and if she wants to compete in her area, she has to. Which brings up a concern I have, is if this notion spreads, we might all have to start playing towards this and posting up things to entice patients. I could just as easily present as a chameleon and feign being XYZ based upon what's more economical in my area of practice - if people want sushi, I'll serve them sushi. As a conservative/libertarian spectrum people have to do, to simply get through the American higher education system. But why? There is beauty in being neutral, apolitical, and just professional.

I'm also seeing more in various masters level therapist websites "Christian based care." What does that even mean? Do you just cite Job every appointment? This just pushes away muslims, hindus, sihks, jains, taoists, buddhists, etc.

I think you are right in that over-sharing is likely to have more patients look elsewhere than it does to attract patients. This could benefit the psychiatrist in getting more of this niche or more like-minded patients or to keep away unwanted patients. That is fine and wonderful if that is what you want. It is unlikely to improve volume in my experience.

Most people find their psychiatrist by geography, word of mouth, Google search, or insurance plan. Very few will enter a search to find a psychiatrist that has similar politics or a similar experience. That isn’t on their mind until maybe they have a terrible experience and find a psychiatrist that resonates strongly with them.

When I search for any physician, I may check my insurance, their training history, reviews, word of mouth, or briefly read the website. If it looks fine, I’ll schedule. I’m more looking for red flags rather than scheduling based on the right political view or life experience.

Someone that posts about their politics, past psych issues, or unique life preferences is likely to send me elsewhere even if we share similar beliefs.

I want an objective diagnosis. I don’t want a psychiatrist or any physician being biased.

If I already know the diagnosis and want a specialist, I’ll look for any specialist. Finding any with openings may be difficult. I’d probably be willing to see someone within a niche specialty despite their personal experiences if I felt that was the only option.

This all comes down to marketing to get the patients we enjoy the most, high volume, or a particular diagnosis.

I try to keep my clinics’ volume up, so my background on my website is very political and belief neutral. I have many patients that would disagree as to which religion, political party, and even what kind of car I drive. My goal is to meet patients where they are at. I’d lose plenty of patients if I specified otherwise.

 

[hamstergang]

No. Absolutely not. I at no point divulge my politics to patients

Ah, my mistake. I think the below post was what I was remembering, but I had it a bit wrong.

Seeing more politically motivated relocations. People coming here to join their fellow *color state* tribe members, and other patients leaving here to join their tribe in *color state*.

 

[hebel]

I am super excited to answer this question for you.

In my opinion (and reasonable people may disagree), the answers are yes, it's good to develop a niche and become excellent at it, no you don't need to do a fellowship in your niche, although it's useful to do advanced trainings, and no, it won't pigeon hole you, because in a cash-practice you can always shift directions based on what you enjoy doing and you also won't JUST be seeing a narrow population of patients in your practice, even if you specialize.

I don't think every psychiatrist needs to have a narrow focus -- I know someone on the thread earlier mentioned being more of a bread-and-butter psychiatrist accepting insurance. We need all kinds of psychiatrists because there are all kinds of patients. So I'm not saying not everyone needs to do what I recommend. If you do, though, it will be rewarding and a lot of fun.

People often use the term "niche" to refer to a diagnosis or specialty (e.g. "my niche is anxiety disorders") but a niche is actually a group of people, so for example, "women 25-45 living in Los Angeles with generalized anxiety." The difference becomes crucial when you are marketing, because a group of people you can find and market to, especially if you think about what other services this group of people use or places they go. A group of people also has multiple problems, not just one. Maybe you start off solving one of their problems, but then you can expand and solve multiple of their problems.

So yes, it's useful to define what niche(s) you want to specialize in, but the more important thing is to define your UNIQUE SELLING PROPOSITION, or USP. This is a general business term, I didn't make it up. A USP is your "special sauce" that will make a patient want to see you as opposed to a different provider. It's the unique value you offer to your patients that prevents you from being a commodity. It can encompass your unique clinical skills, BUT ALSO YOUR PERSONALITY AND LIVED EXPERIENCE. One of the best ways to specialize in a practice is to take what you know well because you've lived it, and translate it into your clinical work.

Let me give use myself as an example. In the home page, "above the fold" (prior to scrolling down) you can see this text:

Ancient Wisdom Meets Modern Medicine
Hi, I’m Elana Miller MD, and I believe that Medicine = Science + Heart.
I’m a psychiatrist passionate about integrating Western medicine, Eastern wisdom, and holistic approaches to help people live fuller and happier lives.
I’m also a cancer survivor who teaches the resilience of the human spirit and the power of love.

It's only a few sentences but it pretty well sums up something unique about who I am and the type of care I offer. It includes a unique area of medicine I've specialized in (integrative psychiatry) but also aspects of my lived experience that have affected how I practice medicine (being a cancer survivor).

I was diagnosed with T-Cell ALL at 31 in my 4th year of residency. I did a three year chemotherapy regimen (yes, THREE YEARS), then was healthy for two years, and then relapsed again at 36 and had a stem cell transplant. It was horrible and traumatic. And yet, this experience has become a major thing that attracts patients to me. This wasn't intentional at all. I wrote a blog about my cancer experience while it was happening, not sure if I would ever practice medicine again or even survive it. But I did, and then I started a practice, and I was hesitant at first knowing I had put out all of these personal essays about myself. However it ended up really helping my practice grow and patients mention this to me all the time when their telling me what led them to reach out.

Patients want a psychiatrist who is skilled and competent, but it also human. They want to see someone who they think will "get" them.

So a niche/USP can be intentional, but it also can be something you fall into because of circumstance.

This is just a single example. I also coach psychiatrists on private practice and here are some of the USPs of the clinicians I've worked with:

• Psychiatrist who traveled to Peru every summer to study (and use) traditional psychedelic medicine who now does psychedelic integration therapy
• Psychiatrist who was a nerd in high school and addicted to video games who went through a self-transformation and now works with adolescent and young adult male gamers to improve their mental health as well as working on grooming, fitness, dating, etc
• Psychiatrist who spent years doing advocacy on climate change and focuses on eco-distress in his practice

You don't have to ONLY see patients who fit into your area of specialty -- half of your practice will probably end up being bread and butter psych. You just want to be the GO TO PERSON for your niche. This will absolutely drive referrals because you will be top-of-mind for potential referral sources when they come across a patient in your niche.

As a side note, I didn't see the thread on the future of psychiatry, but I will say I feel my career is future proofed because of the way I've built my practice and the business platform I've created. I specifically went into psychiatry (as opposed to surgery, which is what I went to medical school to do and thought I was going to do until the end of 3rd year) because of the opportunities to branch out in creative and entrepreneurial ways. It's not that there aren't problems in private practice -- it's just that any problems you have will be under your control to solve (as opposed to working in a bureaucratic system). I love my work, and it's really rewarding to get to feel like you are having a significantly positive impact on your patients' lives.

Tr;dl: Yes, you should niche/specialize. Lean into your specific clinical interests as well as unique lived experience. Become excellent at what you do. Make sure others know what you specialize in so they will send you referrals. Own your own business and your career will be future-proofed.

Small world. I believe I read one of your blog posts detailing your decision to go with psychiatry over another specialty (I think it was urology). It was helpful to me during a time when I was struggling with a similar decision as an MS4 years ago.

 

[Merovinge]

I think you are right in that over-sharing is likely to have more patients look elsewhere than it does to attract patients. This could benefit the psychiatrist in getting more of this niche or more like-minded patients or to keep away unwanted patients. That is fine and wonderful if that is what you want. It is unlikely to improve volume in my experience.

Most people find their psychiatrist by geography, word of mouth, Google search, or insurance plan. Very few will enter a search to find a psychiatrist that has similar politics or a similar experience. That isn’t on their mind until maybe they have a terrible experience and find a psychiatrist that resonates strongly with them.

When I search for any physician, I may check my insurance, their training history, reviews, word of mouth, or briefly read the website. If it looks fine, I’ll schedule. I’m more looking for red flags rather than scheduling based on the right political view or life experience.

Someone that posts about their politics, past psych issues, or unique life preferences is likely to send me elsewhere even if we share similar beliefs.

I want an objective diagnosis. I don’t want a psychiatrist or any physician being biased.

If I already know the diagnosis and want a specialist, I’ll look for any specialist. Finding any with openings may be difficult. I’d probably be willing to see someone within a niche specialty despite their personal experiences if I felt that was the only option.

This all comes down to marketing to get the patients we enjoy the most, high volume, or a particular diagnosis.

I try to keep my clinics’ volume up, so my background on my website is very political and belief neutral. I have many patients that would disagree as to which religion, political party, and even what kind of car I drive. My goal is to meet patients where they are at. I’d lose plenty of patients if I specified otherwise.

I don't think it's even just about appealing to the broadest audience or keeping up volume. There is healing that occurs when someone who does not fit XYZ demographic cares about you and listens or meets ABC demographic of a previous abuser and listens and cares about you. I cannot tell you how many sexual assault survivors I have worked with who said something like "I would only talk to a female therapist, but it's okay because you are a doctor". This occurs after they have gotten a chance to work with me, and is really them having an experience that I can be around an adult male and be safe (even if this is not hitting their conscious thought).

Folks already will see your name and a picture of you before deciding whos services to get. If they want someone of your gender or ethnicity they can select based upon that. I think respecting this in cases of trauma is certainly reasonable but generally would push someone to see any doctor regardless of ethnicity/gender/sexual orientation. It is so fundamental to medicine training to treat every patient as we would want our own family to be treated (and everyone the same) and it's more important than ever in this current political climate for people to feel that care regardless of any group a person does or does not belong to.

 

[G Sheb]

I think people are taking some viewpoints to unnecessary extremes.

Yes, you don't have to have a similar lived experience to treat effectively. And indeed much of the treatment is about recognizing, understanding and accepting differences.
However, it's also sort of out touch to think that your lived experience has no influence on who/what you can treat.
So someone's experience with cancer treatment will obviously influence how they approach and treat cancer patients. Not everyone goes through chemotherapy and can see what it's like to live with this day to day. Does that make them better? I don't know. It will differ from provider to provider, but it will make a big difference.

I worry more about those who think 'they can check themselves out the door' or who think they can be completely 'neutral and objective'. Relationships are inevitable in treatment, and, *newsflash*, you will be part of the relationship whether you like it or not. Better acknowledge what you're bringing to the table, and be aware of your biases, your issues, your experiences and how they could influence the treatment.

Which is the reason why the one person model is pretty much a thing of the past nowadays.

As for self-disclosure, the key question is what are you hoping to achieve.
For some, boundaries are essential. Had an overtly racist borderline patient with anti-immigrant view points, and I had to hold my tongue on repeated question whether I'm an immigrant or not, and somehow connecting to their pain made things work. You should be aware of your reactions even if you don't want to disclose them, and perhaps with other providers, it would have made perfect sense to send them on their way.
For others, self-disclosure can be critical in resolve impasse. But I reserve this for long term therapy treatment with patients with the ability to absorb this kind of information.

 

[Sushirolls]

I think people are taking some viewpoints to unnecessary extremes.

Yes, you don't have to have a similar lived experience to treat effectively. And indeed much of the treatment is about recognizing, understanding and accepting differences.
However, it's also sort of out touch to think that your lived experience has no influence on who/what you can treat.
So someone's experience with cancer treatment will obviously influence how they approach and treat cancer patients. Does that make them better? I don't know. It will differ from provider to provider, but it will make a big difference.

I worry more about those who think 'they can check themselves out the door' or who think they can be completely 'neutral and objective'. Relationships are inevitable in treatment, and, *newsflash*, you will be part of the relationship whether you like it or not. Better acknowledge what you're bringing to the table, and be aware of your biases, your issues, your experiences and how they could influence the treatment.

Which is the reason why the one person model is pretty much a thing of the past nowadays.

Exactly. And you start by keeping your website description apolitical, minimalistic as @TexasPhysician has done.

The one person model? Thing of the past? LOL. No, just wrong.
As Big Big shops and various insurance and PE continue their paths of destruction, solo practices will see an uptick.

 

[clozareal]

Even if I seen things that positively resonate with me, my politics, my hobbies, my 'tribe', whatever, I still won't select them out specifically but avoid them. Why does that matter? Why are they putting that out there? I want a doctor who will be professional, do their job and give me the same quality care they give everyone else - whether I am a Sushiroll or Seaweed salad.

You're assuming that a doctor who shares about themselves is not professional, isn't doing their job, and isn't giving you the same quality of care as everyone else they are seeing. It could be the case, but there are more proximate factors that can tell you that.

 

[G Sheb]

Exactly. And you start by keeping your website description apolitical, minimalistic as @TexasPhysician has done.

The one person model? Thing of the past? LOL. No, just wrong.
As Big Big shops and various insurance and PE continue their paths of destruction, solo practices will see an uptick.

I don't think you understand what 'one person model' means, sushi.

As for the website and how you advertise themselves, if you have a particular unique lived experience that you think can make a big difference on how you approach patients, I don't think it's necessarily bad or says anything about how you practice. Yes, you're limiting yourself, but that's why it's called a 'niche'.

 

[clozareal]

Exactly. And you start by keeping your website description apolitical, minimalistic as @TexasPhysician has done.

The one person model? Thing of the past? LOL. No, just wrong.
As Big Big shops and various insurance and PE continue their paths of destruction, solo practices will see an uptick.

I think G Sheb isn't referring to a solo practice vs health care system, but rather a relationship between a patient-physician as opposed to treating the patient in isolation and no factors from the physicians play into the care.

 

[Merovinge]

Exactly. And you start by keeping your website description apolitical, minimalistic as @TexasPhysician has done.

The one person model? Thing of the past? LOL. No, just wrong.
As Big Big shops and various insurance and PE continue their paths of destruction, solo practices will see an uptick.

He means the One person model as in tabula rosa model or that anything the patient brings to treatment is a result of them, their past, their experiences/interpretations as with classic analytic therapy.

More modern dynamic therapy views the treatment provider as a dyad with the patient and that their experiences will necessarily entangle with the patient. At least this is my understanding being someone with limited knowledge of dynamic therapy.

 

[Sushirolls]

Yep, I'm not aware of the reference of 'one person model.'

Not much more I can add to the world of niche and how it overlaps with polarizing advertising.

 

[SeniorWrangler]

The underlying change is that medicine is shifting from a traditional profession to a consumer-driven business.

If Sushirolls did build his Mental Health Man-Cave and Steakhouse, some people would think it unseemly but a lot of people (OK, a lot of guys) would like it!

 

[ObsequiousAplomb]

There's also a difference of markets here.

Out in rural America and most parts of America, the shortage of psychiatrists means that it's even more important to be available for all types of people. If someone is put off by you in particular then they will have even lower access to care.

In the hotspots where advertising might be more important, patients are looking for "the match" with all of their healthcare providers.

I suffer from a rheumatoid arthritis that has severely impacted my life trajectory. I wanted to undergo analysis while I was in residency for personal growth and development, in addition to plain old curiosity. I just so happened to find an analyst who was a rheumatologist before he became a psychiatrist and then underwent analytic training. For me it was a great match. He has done or said essentially nothing different due to his previous life, but I feel innately more understood than I ever have with prior therapists. Previous therapists repeatedly encouraged me to stop taking the medications, which repeatedly resulted in relapses and pain.

He knows the drugs I talk about taking better than any SW, PsyD, or psychiatrist I would be seeing. I think it's probably interesting to him to hear how much a bread and butter former patient type of his is impacted by the diagnosis and treatment. I'm able to explore the psychological underpinnings of my reactions to the diagnosis and treatment without being goaded into trialing another med-free unpleasant experience.

This is in a hotspot area of the country. If I wanted a different analyst, well, I talked with 10 of them in the two weeks before starting with him. Tbh, the decision at the time was entirely down to the fee and what I could afford as a resident. The fact I got a reduced fee is another huge difference that one could argue is inappropriate. I simply couldn't have afforded the $300-1000 per hour the other analysts (who all advertised themselves as having reduced/sliding scale/affordable rates) bottomed out their rates at when I was making $55k/year.

It's also worth noting that while Sushi is describing the classic method we all seem to have been taught, Sushi has struggled to fill out a panel. The doctors suggesting to carve out a niche through less conventional means seem to have very busy practices. This is likely also fraught with bias for sharing on the forum.

Sushi is extra active here and helping all of us by sharing a lived experience of setting up a practice - I know I have learned a TON from Sushi's posts about myself and what I want from my career. Others are less active, presumably lurking, while sharing a great deal more of themselves both here and to the general public. I know I've learned a lot from them too. I generally strike somewhere in the middle of the two extremes offered here, and only time will tell the results of my efforts.

 

[randomdoc1]

I think overtime our niche kind of naturally happens. We have our own styles, personalities, interests, passions, etc. Coming out of training, I was very much about an evidence based approach with heavy emphasis on a detailed and ongoing working diagnosis and psychotherapy heavy. It's easy to see how someone can become tempted to just become a pill pill making bank doling out benzos and stims. While in the beginning, I made little because many patients found my approach "boring", it paid out in the end. You develop a very stellar reputation and people will flock to pay what you ask, work around your schedule and take your advice seriously because overtime, the evidence based approach is what works and word gets around that people working with you make progress. Some are even impressed by this "naturalistic" and "holistic" approach -- which basically means, "wow! you don't treat everything with benzos and stims?! You're such a naturopathic doctor." lol xD

You become the magical psychiatrist that can help turn life around without having to resort to some heavy duty sledgehammers of medications. Because guess what, therapy works. What a surprise, lol.