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Which subspecialties of psychiatry pay the least/most?

Discussion in 'Psychiatry' started by XWing5000, Apr 11, 2018.

  1. splik

    splik Professional Cat at Large
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    there are 37000 psychiatrists in practice, not sure where 25000 came from. also it's important to remember that most NPs working in psychiatry are not psych NPs, they are FNPs. So in addition to the small number of Psych NPs you also have twice as many FNPs working in psychiatry. Incidentally, the psych NPs seem to resent the FNPs for "taking their jobs" and claiming that these FNPs are not qualified to work in their role. the irony of it all.

    there are lots of cash only and concierge NPs offering mental health services in states with independent practice. some charge more than psychiatrists do.
     
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  3. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Pulled that # off the BLS website--Psychiatrists--and now I see that that accounts for only employed psychiatrists, not "self-employed workers"(obviously a big chunk they missed.)
    However, the point still remains: Psychiatric NPs are not exactly "extremely rare".
     
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  4. michaelrack

    michaelrack All In at the wrong time
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    My guess is that the psychiatrists all have more than one job, so overall they are working more hours than the NP's. That is the situation I am in at my main job. The NP works more hours than me there, but overall, I probably work at twice as many hours
     
  5. MedMan80

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    There was a concierge NP charging patient's 2500/mo here in NYC, seeing kids mind you, the pharmacology was so horrible i won't mentioned it here out of fear of identifying the cases..
     
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  6. NRP

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    Wait wait wait. I don't know any of the lingo here, but each patient/family was charged 2500 a month to see this person?
     
  7. NickNaylor

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    Our local community systems are overflowing with PMHNPs. We have them in our PED (at least 2 on staff) and the outpatient CMHC has predominantly PMHNPs, such that it’s almost a guarantee that you will be seeing an NP unless you’re on an ACT team.
     
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  8. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    Yeah, psychiatric NPs outnumber the psychiatrists down in our OP clinic here. When I was leaving the VA, they had started to hire more and more as well. The last place I was brought on 2 in the last year I was there to backfill some positions. There are shortages, and it sure seems like a lot of systems are going to hire whoever they can to meet productivity demands, MD/DO or not.
     
  9. AD04

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    Any reason for profit-driven entity to hire psychiatrists over NPs? Doesn't insurance reimburse 80% for NPs? If so, why not just hire 2 NPs instead of 1 psychiatrist and make profit through volume? Any penalties legally for having NPs and no psychiatrists?
     
  10. TexasPhysician

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    I thought it was 85%?

    Another psychiatrist friend was just fired today and replaced with a NP. It is becoming increasingly common that NP’s are not being added to supplement us but instead replace us.
     
  11. zolof

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    That is crazy.
     
  12. calvnandhobbs68

    calvnandhobbs68 I KNOW NOTHING
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    Guess the only thing that’s bigger in Texas is the amount of NPs.

    Live in a state that doesn’t allow independent practice folks. Then when they try to lobby for independent practice you’ll have enough doctors in the state to lobby back against it. These stories are worrying but the one plus psych has that most specialities don’t have is the relatively low overhead for private practice. You need a lot more overhead for almost all other specialities, much less the hospital based ones who have no option but to work for another hospital or get paid less.
     
    #61 calvnandhobbs68, Apr 19, 2018
    Last edited: Apr 19, 2018
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  13. ryerica22

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    Honestly, there is so much of a demand for Psychiatrists that it doesnt matter which subspecialty you go in. You don't even have to do a fellowship to do well.
     
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  14. AD04

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    You're right about the 85%, which is ridiculous. But reality is reality. ¯\_(ツ)_/¯

    I wonder if independent NPs are held to the same standard of care in malpractice lawsuits. In the case you mentioned, it's best not to work for those types of employers anyways as they place short-term profits over patient care. Once the NPs mess up, the plaintiffs will go after the employer and there will be no physician to fall back on.

    I wonder how many of the politicians who voted for independent NPs see NPs over physicians for their own personal care.

    Being a psychiatrist is good in the sense of flexibility. You can always open up your own practice and advertise yourself as a physician. You will get patients. When given the option, most people would rather see a physician than an NP anyways.
     
  15. b52bomber

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    I have seen much questionable pharmacology by NPs out in the public. These patients invariably de compensate and come into the psych ED where they are admitted...I read through the notes and try to figure out what their medication regimen, but it has me scratching my head. Usually it’s with how they try to dose the LAIs....


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  16. Candidate2017

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    Psychiatry is traditionally an outpatient private practice field. You are no different from an NP when you work for a hospital in exchange for a salary. No matter how much you believe your training and level of care are superior to a nurse's, you are still an employee. Employees are expendable widgets and no one wants expensive widgets. You are a physician only for purposes of lawsuits.

    Let hospitals implode under the weight of incompetent midlevels, lawsuits, clogged EDs, severely ill patients with extremely long and uncompensated length of stays and uncompensated bounce backs. Hospitals' pocketbooks need to be hit before things get better. Patients will be collateral damage unfortunately.
     
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  17. Stagg737

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    Which I think is the biggest thing psychiatrists have going over many other medical fields. A rash or cold gets mismanaged in the FM clinic by an NP, and it usually resolves itself anyway. Bipolar or schizophrenia gets mismanaged by a psych NP and psychiatrists get to clean up the eventual fallout. Even if NPs start to take over, the psych NPs I've met (other than one who was legitimately fantastic) are so incompetent that I'm not too worried about difficulties finding employment anytime soon. I'll also be doing residency in a state adamantly against mid-level independence though, so that helps.

    Concierge medicine is essentially like being on retainer, so basically you charge a fee and make yourself available to your patients 24/7 as they need you (at least in a true concierge model). DPC (direct primary care) is a similar model, except you charge a monthly fee and patients can see you anytime during allotted office hours. So if something comes up and they need to see you, they make an appointment on short notice. In both models you're basically charging a "membership fee" in exchange for you being more available to the patient than a normal physician would be. This is typically successful because these physicians, I guess providers if NPs are also doing it, have limit their patient pools which remain relatively small and do not take new patients unless spots open up. It's somewhat advantageous because it provides a consistent and predictable monthly income (even if you don't see patients) for the physician, a smaller more manageable patient load, and allows the patient to have better/easier access to their doctor.

    In the given example, the family was probably being charged $2,500/mo so they could have (nearly) unlimited access to care whenever necessary. For a model like that to work with that kind of price tag you've either got to have patients coming from very wealthy families, patients whose care requirements are significant enough that $2,500 actually saves them money, or just patients so pathological that they'll pay that much to have their hands held and have smoke blown up their a$$ about how they're "doing so well" with that provider.

    In states with supervision requirements they obviously have to pay a physician to supervise. In the states with independent practice rights for NPs, there are potential reasons. Increased malpractice risks, increased admits from outpatient clinics, increased re-admission rates due to improper care (which leads to penalties and decreases reimbursement from the gov), and patients who refuse to be seen by non-physicians are just a few. Some of those haven't happened en masse yet in many places, but I'd be willing to bet that once they do (like the post above me suggests) you won't be seeing hospitals or practices which don't at least have physicians on staff as supervisors.


    Getting back on track to the initial question though...

    From what I've heard, addiction is one of the lower paying areas of psychiatry. Anybody have any ideas about how the whole "opioid epidemic" may or may not impact the field? The few physicians I've talked to about it (not psychiatrists) seem to think that we'll see addiction medicine income skyrocket in the next few years thanks to all the attention, but I don't really see how given that most addiction/rehab programs near my city are already constantly full. Any thoughts on that as I'm actually somewhat interested in that area.
     
    #66 Stagg737, Apr 21, 2018
    Last edited: Apr 21, 2018
  18. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Don't go into addiction for the $$.
    If we're going to beat this opioid epidemic--and yeah, it is one--deaths are exceeding annual MVA deaths these days--it's going to happen by changing PCP prescribing habits and community stigma re: medication-assisted treatment, and getting an army of PCPs buprenorphine-certified.
    None of those approaches are going to be lucrative, but they may be exceedingly satisfying for addiction psychiatrists who embrace the advocacy, training, and consult-liaison role to make it happen.
     
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  19. whopper

    whopper Former jolly good fellow
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    The pay highly varies depending on several factors such as private practice, university hospital, state hospital, etc.

    E.g. forensic psychiatrists typically working for a state forensic hospital make an average salary but with good benefits. Doing expert witness work pays very well (hundreds to possibly even over $1K an hour but has no benefits), but this work is inconsistent. A forensic psychiatrist doing expert witness work might do one case then not get another for weeks to months. In the meantime they usually do a usual psychiatric job that's not forensic.

    After going to private practice my pay almost doubled. Well it did if you factor in per hour pay but in terms of actual amount per year it's not double cause I worked about 65 hrs a week as a university professor/clinical doctor but about 48 hrs a week as a clinical private practice psychiatrist.

    Also several forensic psychiatrists I've seen don't work as forensic psychiatrists. They get a job as a regular psychiatrist and then it just takes over cause the forensic work can be inconsistent. Also several jobs won't allow forensic psychiatrist the flexibility needed for forensic work. E.g. let's say you need to testify on a case so you need the day off from work. They'll say you're not allowed to do it unless you make it a vacation day. It's "work?" No it's not to them cause you signed on a contract to work for them and any work on the side is not considered part of your agreement with them.
     
  20. sluox

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    Not disagreeing with your gestalt at all, but to be fair, there's definitely money to be made in addiction. It depends on a lot of factors. Talking to a lot of people my sense is that the fellowship is financially worthwhile. Employed jobs "requiring" a fellowship or equivalent (i.e. medical director level) typically has a pay premium of 10-20% compared to a regular entry level job. Those don't pop up as frequently tho.

    In the private world, the total revenue for an addiction practice can be sky high and via a variety of good/bad practices. Addiction is also an interesting field if you are into running businesses. It appears that some of the truly wealthy community addictionologists own significant equity in large treatment centers. It appears realistic, if rare, to secure 8 figure net worth in this field in midlife and I have on occasion met one or two at one of the trade meetings.
     
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  21. uhmocksuhsillen

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    Any idea what a full load suboxone practice can generate? I'm guessing these aren't hard practices to fill either with how things are going these days either..
     
  22. Blitz2006

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    Good question.

    Keep in mind the limit is 275 patients per year (if I'm not mistaken)

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  23. Blitz2006

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    I agree.

    From what I've seen, the average job may give an extra 10 or 20k/ for any fellowship training.

    So over a 30 year period, you may earn an extra 300 to 600k. But also remember you lose a potential 150k to 200k doing a fellowship year.

    So at the end of your career, you make an extra 400k tops with fellowship.

    Which is peanuts compared to other specialities where your salary can literally go from 200k to 500k, or in surgical fields, 300k to 600k per year.

    So relatively I think this is why people say financially, fellowships are not beneficial outside of child psych.

    Although even child psych, unless you are doing cash in NYC or LA, I'm not sure how much more value it adds, but I'm sure child Psychiatrists on here can add their 2 cents.

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  24. uhmocksuhsillen

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    That sounds right...I think the first year is only 30 patients though?
     
  25. Blitz2006

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    I believe you are correct. 2nd year was 100, but then they recently increased to 275.

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  26. TexasPhysician

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    My understanding:
    1st year is 30
    Afterwards you can apply for 100.

    If boarded or fellowship trained in addiction, you can apply for 275.

    These are for active patients, not per year.
     
  27. Blitz2006

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    Oh really? So a boarded general Psychiatrist can only do 100? Didn't know.

    Thought 275 was for anyone with a waiver.

    I also didn't know you had to be board certified to prescribe Suboxone!

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  28. TexasPhysician

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    Without specific training, physicians can’t handle over 100 Suboxone patients. Apparently your brain will cave in or something.
     
  29. yanks26dmb

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    I finished an addiction elective not long ago and really enjoyed it...so much so that I would consider doing only that type of work after fellowship.

    Any idea if it would be reasonably easy to fill up a panel of 275 patients (without moving to the boonies) AND would it make financial sense to do only that?
     
  30. Blitz2006

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    I'm sure it's pretty easy to fill. Not so sure how financially rewarding it is.

    Remember, you don't need to be an addiction psychiatrist to get a Suboxone waiver. Even internists can prescribe it.

    So not sure if prescribing suboxone is well worth your "specialized" knowledge. Definitely offer it to patients who need it, but not sure how beneficial it is to have your entire practice revolve around Suboxone (as a Psychiatrist).

    The more important issue is getting more physicians around the country of all specialities to get their waiver, therefore improving access for patients.

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  31. resident1985

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    Depressing to hear from someone planning on applying for sleep in the next cycle :(
     
  32. notdeadyet

    notdeadyet Still in California
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    I agree with this.

    It takes longer to build a good forensic practice than a good private practice, and the work is unpredictable. You get a nice wage. It's not hard to get $300-$600/hour, with criminal cases on the lower end of the scale and civil work on the higher end.

    But this is almost impossible to pull off full-time. Aside from the scheduling issues, you get good pay by doing good work and the WORST forensic psychiatrists are those who don't maintain clinical skills. Their work is shoddy and they tend to be bottom feeders, which is great for a quick buck but they typically find it harder to get decent (i.e. higher paying and higher hours) cases due to reputation. The best way to make a decent living in forensics is to maintain a paid faculty appointment, but it's tough finding one that is compatible with taking frequent time off to meet with lawyers and testify in court.

    Regarding getting time off, most employers I've talked to indicated that any time away is vacation time. The only time I testify in court without taking the day off (or comp time) is if I'm subpoena'd as a fact witness, NOT for my forensic practice. And if you get a faculty appointment, many places will charge you a 15-25% fee for any forensic work you do on your off hours (although in these cases, they'll also often help with billing, office space, and malpractice). And some places will have you sign a contract forbidding that you do forensic work on your off hours (I'm looking at you, Kaiser).

    I definitely make a higher hourly rate as a private forensic psychiatrist than I could make in any other area of psych. But I definitely can't multiply my hourly rate by 40 and call myself done.
     
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  33. Blitz2006

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    Awesome post.

    So roughly how many hours a week do you do just forensic work? And what is realistically the average forensic Psychiatrist number of hours doing just forensic work?

    10? 15?

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  34. splik

    splik Professional Cat at Large
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    I would add that 15-25% is on the low side for the cut the you might have to pay if you are faculty somewhere; many places are closer to 50% when you take into account both departmental and deans taxes. I get taxed at the lower end but they plan on substantially increasing that in years to come such that it might not be worthwhile. They also do not help with billing or malpractice though I do use my office. There are some institutions that don’t take a cut if you do it on your own time. On the plus side my schedule is flexible and my boss supportive so I can do forensic evals during the day or report writing during office hours and do not have to take leave to testify in court.

    I do roughly 10hrs/week forensic work on average but that can be lots one week (like this week) and nothing another week. It is hard on top of a more than full time job but I enjoy the work and feel like I’m still early on that I can’t say no until I establish my practice further.
     
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  35. nancysinatra

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    I disagree with this statement - I don't think a "shortage" of psychiatrists has anything to do with the current "mental health crisis." The number of psychiatrists relative to the general population is probably not that much different now than it was in, say, 1950. (I don't actually know if this is true - but I assume so. I'd love to see some stats and find out the truth.) But over the past half century, long term psychiatric hospitals closed creating a flood of untreated patients, new conditions (i.e. ADHD, social anxiety) were identified, some new treatments emerged (ie. SSRIs) that were then marketed by big pharma to the masses, etc. Changing attitudes around mental health in general and the destigmatization of substance abuse, depression, etc. has probably also had the effect of "creating" more patients, in the form of people who now seek treatment who in the past would not have. Add to that the growing economic anxieties being placed on the American middle class. I think THOSE factors created the perception that there is a "mental health crisis." Whether it's one that more psychiatrists can fix, I have no idea.
     
  36. nancysinatra

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    My impression in the midwest is that you can go into forensics with or without a fellowship. Your potential clients (lawyers and courts) don't necessarily care about the fellowship credentials. If I really wanted to make the most money possible in this part of the country, I'd work on developing an expert witness service, without the forensic credentials.

    Regarding sleep and (less so) pain - I wish that general psych residency spent more time on these.
     
  37. sluox

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    LOL, the federal govt is trying REALLY hard to get people to do this. Sadly, most of your 275 will be Medicaid or worse (i.e. no insurance at all), and it's unlikely to make this work unless you are doing some very creative things, which some people are doing, to varying degrees of success. Some of your patients will overdose and die. Some will sue. Many have severe comorbid psychopathologies and may commit suicide and require lots of unbillable family meeting time. Running a Suboxone pill mill is not an easy job to make big money in psych--and this is why it appears only the bottom of the barrel people do it unless you are medical director of a large, often academic or govt program and are def not in it for the money, or if you have some interesting arrangement with a practice owner. Remember Stark law--can't practice where you own.

    You won't be able to fill 275 with high functioning professionals who are pill users and a pleasure to work with, but if you are a rockstar you can make a million+ < 100 of those.
     
  38. TexasPhysician

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    May want to explain your thought a bit more. By this reasoning, every private practice is in violation.
     
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  39. whopper

    whopper Former jolly good fellow
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    Adding to what was written above about forensic psychiatry...
    Another dynamic is forensic psychiatry is much more labor-intensive. E.g if you testify on a big case the stress level is like prepping for a medschool exam cause if you testify you need to be able to talk about opinion in a manner as if it's an oral exam with the cross-examining lawyer acting as if he's trying to fail you.

    While if you spent the same exact amount of time working in your office 85% of the time is usual work that isn't very stress-provoking.

    And sometimes you deal with a-hole lawyers. E.g. you testify on a case for 1 hr but had to be in court for 6 hrs while you waited, you're supposed to bill for 6 but the idiot lawyer doesn't want to pay you despite that he's billed for waiting in court too and you and he signed a contract firmly establishing how you were going to charge and how he was going to pay. Then he starts pulling lawyers tricks to get out of it, like sending nicely worded letters that basically say "phuck you and your mom and while we're it expect a war if you want your pay," so this becomes a headache when you just could've worked those same hours in a office and not expected this out-of-nowhere headache on a case you spent a lot of time and effort.
     
  40. Blitz2006

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    I agree.

    Maybe in NYC or LA you can fill 275 with good insurance/cash...but that's probably it.

    Let's be honest, if Suboxone was a cash cow, a lot more physicians would have the waiver (including non psychiatrists). And yet we are struggling as a medical community to get physicians waivered up...

    If you really want to make $, much easier ways in Psychiatry...you can even do Botox if you want...I heard that even RN/NP can get Botox certified.



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  41. OldPsychDoc

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    Gee--you're almost making want to be a forensic psychiatrist there, whopper...
     
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  42. Stagg737

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    I'm in a mid-sized midwest city and the demand for any CAP is ridiculously high. You could easily do a cash practice here and be very successful in pretty much any area of psych where I'm at, especially child.

    Could you elaborate a little on criminal vs civil forensics? I feel like I have a basic understanding (maybe not) of criminal but don't really know what the civil side would entail.
     
  43. sluox

    Physician 10+ Year Member

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    So I'm thinking specifically in the instance where there is a large treatment facility with a referral source. Because of Stark law, you can't also own the receptive referral source. So, you can't own a detox-rehab, and then refer yourself patients there, then treat the patients outpatient yourself. You can obviously own your own practice and treat patients there.

    There are weird exceptions to this. For example, I know of a well known detox-rehab chain that has a single physician group as a referral source. So while the detox-rehab itself cannot be physician owned, the partner equity of the physician group is really essentially tied to the value of the detox-rehab. I'm not sure how they carved out Stark safe harbor, but my knowledge is that a bunch of lawyers created this workaround.

    This is all Medicaid. Commercial insurance totally different.

    The bottomline is, the suboxone clinic itself wouldn't be profitable, but it might provide you with a profitable referral source, if you can somehow derive value from more intensive treatment.
     
  44. watto

    watto Sleek White Pantsuit
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    Not the same experience as Whopper's, but there is some work in doing a good Independent Medical Eval. I do them for the state Worker's Comp administrators. You get a flat rate if the chart is an inch thick or five times that. But they pay you for so many other components of the workup (phone calls to clarify points with attorneys, depositions, testifying if needed) that it ends up being fairly lucrative. I enjoy doing them on the side as it has a forensic flavor and requires a high level of critical thinking.

    Love me some M-FAST. Wish they would have taught some of the malingering screeners in residency (also to Whopper's point in another thread).
     
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  45. splik

    splik Professional Cat at Large
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    True civil forensic psychiatry is regarding civil competencies eg testamentary capacity, undue influence, financial capacity, matrimonial capacity, contractual capacity, medical decision making capacity. Civil commitment, guardianship, conservatorship issues as well.

    In actuality much of the civil work is just regular expert witness work that does not require forensic expertise such as personal injury, sexual harassment, disability discrimination, medical malpractice. All those people suing for emotional damages etc.

    Some people consider (mistakenly) disability work to be civil but it’s not really related to civil law and often takes place in different courts.

    Similarly immigration/asylum issues are often lumped under civil but immigration court is its own thing too and most people who do this work (which often pays poorly) are not forensic psychiatrists
     
  46. Stagg737

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    TY. I figured the first sentence in the bolded would fall under civil, but didn't realize guardianship/conservatorship falls under that umbrella as well.

    Interesting. I'm extensively familiar with the IME process for ortho/trauma injuries and WC, but didn't realize this was actually something you could do for psych. Is it a pretty similar process (see the pt and render an opinion with possibility of being called to testify) or is there more or less to do on the psychiatric side?
     
  47. watto

    watto Sleek White Pantsuit
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    Yes, in my state at least, there is a high demand for psychiatrists willing to do IMEs. I have seen IME reports by psychologists, neurologists, ortho, ENT, ophtho, just about every speciality excepting family practice.

    Your job is to complete chart review and then perform a patient interview to answer questions (in my case) posed in a cover letter by the state WC insurance carrier. I don't do IMEs for claimants or their attorneys specifically, just the state carrier. The queries usually involve rendering and supporting a diagnosis, if any, and discussing etiology of any psychiatric disorders. You are asked to render an opinion on what weight a work exposure may have had in the development of any diagnosis. You end up making a lot of polite comments on the "eclectic" treatment people have had for various questionable conditions, if you know what I mean.

    The interviews take about an hour and a half average, the prep time and report can be a few hours. My reports are 22-25 pages (you need to document everything you have reviewed in the chart that is pertinent). PM me if you are interested in my rates - in my case, they are set by the state.
     
  48. whopper

    whopper Former jolly good fellow
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    As has been my experience too but I'm talking about the big money making cases that people are talking about for money. I've done independent evals too ...I don't know what you mean by "fairly lucrative," cause those independent evals end up making me about as much as private practice anyway where I make about $300/hr. I've done independent evals for over $500/hr but they're much more labor intensive to the degree where sometimes I don't find them being worth it. Bear in mind I got 2 kids now taking up a lot of my time. When this happens to a lot of poeple including me the drive to be a type-A shark alpha wolf isn't as strong.
     
  49. watto

    watto Sleek White Pantsuit
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    For me, the avg/hr is more given that 60-70% of the cases end up requiring additional input, which I am paid for but essentially already done the work for. I get a lot of scheduled testimony where things get settled but I still get half the fee if they don't cancel within a specified time. Then I book private practice patients in that slotted time and treat myself to a brand name soda that afternoon...
     
  50. NickNaylor

    NickNaylor Thank You for Smoking
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    Really living large there.
     
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  51. nancysinatra

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    Splik and other forensic psychiatrists here - have you ever actually been called upon to weigh in on a case of matrimonial capacity?

    I would do a forensic fellowship if for no other reason than to get first dibs on matrimonial capacity cases. Because it seems interesting. Like, what if the case involved an arranged marriage? Or if the bride was really young? Or if she was a mail order bride and spoke no English?

    It’s also interesting the things that require capacity, and those that don’t - ie matrimonial capacity is a thing, but parental capacity is not. I don’t suppose they cover that in the fellowship?
     

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