work options....

[vistaril]

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As many of you know I haven't been working full time for the last 4-5 months or so. Contracts ended and it's time to find something permanent. Need to stay in the area so responses like "all those jobs are terrible move and find better ones" are not useful.

option 1- all outpt cmhc. Pays 170k a year plus benefits(but not good ones...they fund a 401k at a paltry 3% matching but only after 1 year, the health insurance they offer isn't cheap or that good or subsidized much, and they cap cme/license/whatever reimbursement at 750 dollars per year). 4 weeks total sick/vacation. Would be 40 hours per week with 'phone pager' call for late night emergencies one week per 6. You get 15 minutes for f/us but only 75% of the patients show on average so in reality you're going to average 3 followups per hour. They give you 30 mins for intake but the therapist does an intake before you where they collect a ton of info to make it quicker for you. There is no non-clinical time so you are expected to chart on your own time(for
me that would be during the visits and during no shows). It's pretty much a strictly med mgt job(obviously).

option 2- all inpatient job at smaller outlying hospital. No salary or benefits. Eat what you kill, but the problem is the unit caps at 14 patients. In exchange for me signing on they are willing to give me exclusive access to all those patients. Some are not going to be insured of course, and I'll still have to see them(and that of course is going to reduce the number of possible paying patients). No subsidy, and I pay for everything on my own(my malpractice). There is no support whatsoever except granting me complete access to the unit. I'd have to set up my own billing apparatus. I'd have to get on all these panels that I'm not on now and that will take forever. Additionally with the way deductibles are now, I'm worried about collection rates even on the insured patients. This job would also require significant travel, which would really prevent me from getting home early to then do some other outpt work(it would be a long ass commute, even if I moved to the more convenient side of town). With this job I just worry about the total reimbursement potential in terms of what my collections would actually be. A few of the 14 beds at least are probably going to be taken by uninsured patients(or patients where the ins company stiffs me or cuts off the stay). Given all the dollars I would have to pump into this job(buying my own malpractice, setting up my own billing/collections) and the way the reimbursement is going to be essentially capped and problems with collections I would anticipate, I don't know that I would even pull 140k from this job after expenses.

option 3- full time job working for a company that contracts out with prisons. It's a perm job that could go on indefinately, but it's actually a contract job. So no benefits. It's also a 1 hr commute one way. The job pays 180k(but again no benefits apart from my medmal being covered and they will cover license fees). Only 3 weeks vacation/sick time. Job is M-F 40 hrs week. I wouldn't actually have to see the patients in the prison, but in an outpt multispecialty clinic(really just psych and primary care it seems). Don't really know a lot about prison work or this population. They told me I would be expected to see about 20 patients a day from various jails/prisons(and I think some probationers and parolees too). On paper this doesn't look so bad but I don't really want to work with this population.

So.....which one would you pick?

 

[trophyhusband]

So you already know I'm not a doc but my wife is... so you can ignore this if you want but:

If it were my wife I'd tell her to negotiate whatever she could out of #1 and #3 and then go to #2 and say these are the offers I have on the table and try to negotiate a salary guarantee for a year (or two) and then move to an RVU based position once the guarantee ends. If I'm reading it correctly they already have a unit but it's currently not in use? Or are they using locums or something? If it's the former they have a overhead in the form of building and maintenance but no revenue covering it (and if you do come on board they'll be billing a facility fee to the insurers and Medicare so they're trying to get their cake and eat it too). If it's the latter well then they're currently paying someone to do the job. If they won't negotiate a W2 job with you walk... it doesn't sound like anyone else is currently knocking down the door to work with them.

All of those options are brutal though... where do you live that these are the only options? Bleh.

 

[Not_a_psychic]

What part of the US are these jobs located?

 

[vistaril]

So you already know I'm not a doc but my wife is... so you can ignore this if you want but:

If it were my wife I'd tell her to negotiate whatever she could out of #1 and #3 and then go to #2 and say these are the offers I have on the table and try to negotiate a salary guarantee for a year (or two) and then move to an RVU based position once the guarantee ends. If I'm reading it correctly they already have a unit but it's currently not in use? Or are they using locums or something? If it's the former they have a overhead in the form of building and maintenance but no revenue covering it (and if you do come on board they'll be billing a facility fee to the insurers and Medicare so they're trying to get their cake and eat it too). If it's the latter well then they're currently paying someone to do the job. If they won't negotiate a W2 job with you walk... it doesn't sound like anyone else is currently knocking down the door to work with them.

All of those options are brutal though... where do you live that these are the only options? Bleh.

I've already tried to go the guarantee/salary route with job #2. Not happening. The unit was being covered by a retiring psychiatrist who had a psych np handle most everything hands on and he would come over and sign charts. The psych np took a job at a local cmhc so I wouldnt be getting her.

I live in a southeastern city(although this job isn't there but about an hour and ten minutes at least away)

 

[vistaril]

What part of the US are these jobs located?

southeast

 

[trophyhusband]

I've already tried to go the guarantee/salary route with job #2. Not happening. The unit was being covered by a retiring psychiatrist who had a psych np handle most everything hands on and he would come over and sign charts. The psych np took a job at a local cmhc so I wouldnt be getting her.

I live in a southeastern city(although this job isn't there but about an hour and ten minutes at least away)

Is the current psychiatrist working under the same deal they're offering to you? If so how could he afford to pay the psych NP? Or was the NP and employee of the hospital? If the NP was an employee you should have even more leverage as they're losing that salary and can afford to give you a guarantee and put you on an RVU system... they're just not desperate enough to realize it yet. When is the doc retiring? If it's soon I'd make one more pass at it noting the NP salary will be going away so they can afford to bring you on... when they say no just take one of the other jobs and tell them to give you a call when he actually retires. Sounds like they're playing hardball, maybe they'll find someone to take that deal but I doubt it because it sucks.

Edit: Hospitals are loath to let units sit vacant for long (even rural ones) so when he moves closer to retirement they'll be in panic mode and you can take advantage then. Also, you might suggest they contact some locums agencies and do a cost comparison of putting you on salary (minus the savings of the NP if they were employed) vs. hiring a locums for any amount of time.

 

[sunlioness]

I'd be hunting down an Option 4 ...


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[st2205]

I know you're a big believer that facilities will only pay a psychiatrist what they generate directly on paper but I'd be asking for a salary from #2 that's subsidized from the money they're generating from their own billing. Sounds like they're losing a psychiatrist to retirement and can't keep the midlevel. What options do they have?

I'd come up with a dollar figure of what you think would be fair for that job, tell them and, if they balk, tell them you're taking one of the other offers. Worst thing that happens is they say no. More likely, they go back to the drawing board and have to see what they're willing to spend to continue to generate revenue. If the numbers don't add up, I'd bet they'd counter with an offer that moves in the right direction, unless they've got a lot of people waiting in the wings (doesn't sound like it).

 

[cookymonster]

As many of you know I haven't been working full time for the last 4-5 months or so. Contracts ended and it's time to find something permanent. Need to stay in the area so responses like "all those jobs are terrible move and find better ones" are not useful.

option 1- all outpt cmhc. Pays 170k a year plus benefits(but not good ones...they fund a 401k at a paltry 3% matching but only after 1 year, the health insurance they offer isn't cheap or that good or subsidized much, and they cap cme/license/whatever reimbursement at 750 dollars per year). 4 weeks total sick/vacation. Would be 40 hours per week with 'phone pager' call for late night emergencies one week per 6. You get 15 minutes for f/us but only 75% of the patients show on average so in reality you're going to average 3 followups per hour. They give you 30 mins for intake but the therapist does an intake before you where they collect a ton of info to make it quicker for you. There is no non-clinical time so you are expected to chart on your own time(for
me that would be during the visits and during no shows). It's pretty much a strictly med mgt job(obviously).

option 2- all inpatient job at smaller outlying hospital. No salary or benefits. Eat what you kill, but the problem is the unit caps at 14 patients. In exchange for me signing on they are willing to give me exclusive access to all those patients. Some are not going to be insured of course, and I'll still have to see them(and that of course is going to reduce the number of possible paying patients). No subsidy, and I pay for everything on my own(my malpractice). There is no support whatsoever except granting me complete access to the unit. I'd have to set up my own billing apparatus. I'd have to get on all these panels that I'm not on now and that will take forever. Additionally with the way deductibles are now, I'm worried about collection rates even on the insured patients. This job would also require significant travel, which would really prevent me from getting home early to then do some other outpt work(it would be a long ass commute, even if I moved to the more convenient side of town). With this job I just worry about the total reimbursement potential in terms of what my collections would actually be. A few of the 14 beds at least are probably going to be taken by uninsured patients(or patients where the ins company stiffs me or cuts off the stay). Given all the dollars I would have to pump into this job(buying my own malpractice, setting up my own billing/collections) and the way the reimbursement is going to be essentially capped and problems with collections I would anticipate, I don't know that I would even pull 140k from this job after expenses.

option 3- full time job working for a company that contracts out with prisons. It's a perm job that could go on indefinately, but it's actually a contract job. So no benefits. It's also a 1 hr commute one way. The job pays 180k(but again no benefits apart from my medmal being covered and they will cover license fees). Only 3 weeks vacation/sick time. Job is M-F 40 hrs week. I wouldn't actually have to see the patients in the prison, but in an outpt multispecialty clinic(really just psych and primary care it seems). Don't really know a lot about prison work or this population. They told me I would be expected to see about 20 patients a day from various jails/prisons(and I think some probationers and parolees too). On paper this doesn't look so bad but I don't really want to work with this population.

So.....which one would you pick?

I'd avoid Option 2 at all costs. You should be making at least twice what you think you'll make for that kind of job. And if they are having that much trouble getting doctors, you can bet there are going to be days where the unit is understaffed too. If they block beds for that, you are pretty well screwed. And I personally would never want an inpatient job where I'm financially incentivized to get acutely sick people out because I'm forced to treat them for free.

The commute for option 3 is a killer. Think about it, you're working 225 days a year at that job and every day requires 2 hours in your car. What are those 450 hours worth? Most psychiatrists could make $70,000 for that time. No thanks.

So I guess Option 1 is the best of a lousy bunch, although those 30 minute intakes sound awful. If their therapist positions are as uncompetitive as their psychiatrist positions, I wouldn't count on getting a lot of useful history from their intakes.

 

[nexus73]

Is the a better locums job nearby with better terms which might convert to permanent?

 

[Bartelby]

Is starting or joining an insurance based private practice off the table? If the employed jobs are that bad in your area you could probably offer better care setting up your own practice (taking only 1-3 of the best insurance plans), and I think it's likely you could beat those salaries with fewer hours per week. That does come with the headaches of running a practice, though.

Of the three I would consider the CMHC, but I would try to aggressively negotiate because they probably really need someone. Maybe bump intakes to 45 mins with a psychologist prescreen and followups to 20 mins each (with the no-show rate gives a 2-3 per hour rate)? I would also really scrutinize how much support that CMHC has in place, as a good team could be the difference in that job being relatively okay versus a complete nightmare.

 

[OldPsychDoc]

Move.

 

[Doctor Bagel]

There are all horrible options. You could probably do locums somewhere else for a few months of the year and make the same income -- would that work for your life? It might beat driving 2 hours a day for an already crappy job. As said above, I'm imagining psychiatric care in your community is pretty poor. With that, there are probably some people with resources who are desperate and would be willing to pay for treatment. What about at least a part-time cash pay practice or very limited insurances accepted type of practice?

The hospital deal as is sounds especially bad because I'm guessing you're in a state that did not accept the Medicaid expansion, which means a lot of the people are going to be uninsured. I'm also not seeing any benefit of the prison job over the CMHC job. Pay is the same, commute worse, benefits worse, higher liability. Also all the prisoners are going to show up, whereas at the CMHC you can count on some no shows to open up your day a little.

 

[Shikima]

Dude, at least the VA will give you 5% matching in a 401k than the CMH with the same level of nonsense, plus be paid more and better benefits.

 

[Doctor Bagel]

Dude, at least the VA will give you 5% matching in a 401k than the CMH with the same level of nonsense, plus be paid more and better benefits.

Didn't vistaril say he wanted a VA job? Maybe that's not working out for him in his area. This thread makes me sad.

 

[medium rare]

Didn't vistaril say he wanted a VA job? Maybe that's not working out for him in his area. This thread makes me sad.

Don't be afraid to ask for what you want. CMHCs are generally desperate for psychiatrists regardless of geographic region. I wouldn't take any of these options as a psychologist/psych NP and, as a psychiatrist, you should have even greater bargaining power. Local CMHCs call my office every few months trying to tempt me to come work for them (they seem to forget I hung up on them the last time they called) or one of the medical directors corners me at one of the few pharma dinners I attend and tries to persuade me to give them a day a week or something along those lines. Sometimes, just for kicks, I tell them the compensation I would need to even consider the possibility and they always say the could never manage that and then, mysteriously, someone calls a week or so later and offers what I asked for. It's worth a laugh if nothing else.

 

[vistaril]

Is the current psychiatrist working under the same deal they're offering to you? If so how could he afford to pay the psych NP? Or was the NP and employee of the hospital? If the NP was an employee you should have even more leverage as they're losing that salary and can afford to give you a guarantee and put you on an RVU system...

yes I've been asking for more now for almost three months from them in terms of all these things....they haven't budged. I guess I could continue to ask for these things and wait another 3, 6, etc months

 

[vistaril]

Dude, at least the VA will give you 5% matching in a 401k than the CMH with the same level of nonsense, plus be paid more and better benefits.

I've been trying to get on there but there are no openings.

 

[vistaril]

There are all horrible options. You could probably do locums somewhere else for a few months of the year and make the same income -- would that work for your life? It might beat driving 2 hours a day for an already crappy job. As said above, I'm imagining psychiatric care in your community is pretty poor. With that, there are probably some people with resources who are desperate and would be willing to pay for treatment. What about at least a part-time cash pay practice or very limited insurances accepted type of practice?

The hospital deal as is sounds especially bad because I'm guessing you're in a state that did not accept the Medicaid expansion, which means a lot of the people are going to be uninsured. I'm also not seeing any benefit of the prison job over the CMHC job. Pay is the same, commute worse, benefits worse, higher liability. Also all the prisoners are going to show up, whereas at the CMHC you can count on some no shows to open up your day a little.

I can't do locums here(no locums jobs here) and I need to stay within an hour or so of here for family/personal reasons.

 

[vistaril]

Move.

As noted in the OP, this is not an option.

 

[vistaril]

Is starting or joining an insurance based private practice off the table? If the employed jobs are that bad in your area you could probably offer better care setting up your own practice (taking only 1-3 of the best insurance plans), and I think it's likely you could beat those salaries with fewer hours per week. That does come with the headaches of running a practice, though.

Of the three I would consider the CMHC, but I would try to aggressively negotiate because they probably really need someone.

I have already negotiated for the last 3 months with these jobs. Aggressively.

 

[vistaril]

I'd avoid Option 2 at all costs. You should be making at least twice what you think you'll make for that kind of job. And if they are having that much trouble getting doctors, you can bet there are going to be days where the unit is understaffed too. If they block beds for that, you are pretty well screwed. And I personally would never want an inpatient job where I'm financially incentivized to get acutely sick people out because I'm forced to treat them for free.

The commute for option 3 is a killer. Think about it, you're working 225 days a year at that job and every day requires 2 hours in your car. What are those 450 hours worth? Most psychiatrists could make $70,000 for that time. No thanks.

So I guess Option 1 is the best of a lousy bunch, although those 30 minute intakes sound awful. If their therapist positions are as uncompetitive as their psychiatrist positions, I wouldn't count on getting a lot of useful history from their intakes.

their psychiatrist positions are not that noncompetitive. They have one opening and can find someone decent here to fill it if I don't accept in the next 2 weeks.

 

[Psychotic]

#1 is the one I would pick if I had no other options...but I agree with others - move.

 

[Shikima]

I've been trying to get on there but there are no openings.

No jobs you say? I see 170 openings.
https://www.usajobs.gov/Search/?Key...ompleteSelected=False&CanSeekStatusJobs=False

 

[MLT2MT2DO]

#1 is the one I would pick if I had no other options...but I agree with others - move.

If he moved he couldn't be so miserable, hence not an option

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[scudiera]

Damn...these options are bumming me out :\ Good luck.

 

[Trismegistus4]

Do you need to be in the area round-the-clock? If not, what about one of those 2 weeks on/2 weeks off hospitalist jobs? I've had recruiters try to pitch a couple of those to me. You can do those locums, too, so you're not committing to anything. They'll fly you to rural Arkansas or rural Wisconsin or wherever the desperate hospital is, you "grind" away for 2 weeks, then fly home and do whatever family/personal stuff you want for 2 weeks.

 

[Doctor Bagel]

Do you need to be in the area round-the-clock? If not, what about one of those 2 weeks on/2 weeks off hospitalist jobs? I've had recruiters try to pitch a couple of those to me. You can do those locums, too, so you're not committing to anything. They'll fly you to rural Arkansas or rural Wisconsin or wherever the desperate hospital is, you "grind" away for 2 weeks, then fly home and do whatever family/personal stuff you want for 2 weeks.

This is what I'm wondering. I think you could spend about as much time with family with a job like this as you could with a busy 5 day a week job that also requires a 2 hour commute.

 

[notdeadyet]

Damn...these options are bumming me out :\ Good luck.

Why? There are pockets of the country where you will not have a lot of professional opportunities. But these are rare and you will know about them ahead of time.

If you work hard to become a good psychiatrist, perform well enough in residency that you establish a good reputation, and don't have a do-or-die relationship with a single geographic locale, you'll likely be fine.

 

[vistaril]

If he moved he couldn't be so miserable, hence not an option

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again, moving is simply not an option. I appreciate the people who have responded with constructive comments in this thread(as opposed to those who apparently can't read where I said moving is not an option). I think I'm leaning towards option #1. I have another week or so to decide.

 

[vistaril]

No jobs you say? I see 170 openings.
https://www.usajobs.gov/Search/?Key...ompleteSelected=False&CanSeekStatusJobs=False

none of these openings(well not one that I'm eligible for) is where I need to be.

 

[vistaril]

Do you need to be in the area round-the-clock? If not, what about one of those 2 weeks on/2 weeks off hospitalist jobs? I've had recruiters try to pitch a couple of those to me. You can do those locums, too, so you're not committing to anything. They'll fly you to rural Arkansas or rural Wisconsin or wherever the desperate hospital is, you "grind" away for 2 weeks, then fly home and do whatever family/personal stuff you want for 2 weeks.

I've thought about this, but when you look at travel and such back and forth that leaves only 12/28 days at home. Then subtract a few more days for being out of the city for various other reasons per month, and I'd be looking at less than 10 days per 28 where I am actually 'home'. Not enough imo.

 

[trophyhusband]

yes I've been asking for more now for almost three months from them in terms of all these things....they haven't budged. I guess I could continue to ask for these things and wait another 3, 6, etc months

Yes, that's essentially what I'm saying.

Couple of things to think about:

1. Has the NP already left for the CMHC?

• If so, then look at a calendar and go 3 months out from the date the NP left and contact the hospital around then. If it's still a no go then try 3 months after that. I'm willing to bet that the psychiatrist will be ready to retire for sure within 6 months as he'll now be doing all the work himself.
• If not, well it's just a waiting game until the NP is gone because as I said the doc will retire shortly thereafter as he's not going to want to do the work himself after having the NP do everything for so long.

2. Was the NP an employee of the doc or the hospital?

• If the NP worked for the doc it's possible you're vastly underestimating the income potential for the position.
• If the NP worked for the hospital then there's wiggle room for you to negotiate if you can hold out long enough.

 

[Merovinge]

I've thought about this, but when you look at travel and such back and forth that leaves only 12/28 days at home. Then subtract a few more days for being out of the city for various other reasons per month, and I'd be looking at less than 10 days per 28 where I am actually 'home'. Not enough imo.

I have a friend who took this scheduling for her first job post residency (admittedly in Neuro, not psych, but not that different logistically). If you are traveling to a somewhat nearby area and they are covering your flights, it is nowhere near a full day of travel. Her flight will be about an hour, say plus two hours for airport shinanigans/transport and you still easily get a nearly full day. Also consider that the days you have you are not working and thus, are worth much more than say a workday where you get home at 7PM at night.