Medical Education US

im considering going into psychiatry, but eventually i know i want to start my own company so I am leaning towards working strictly in a hospital that way i dont need to worry about paying off loans i take out to start my own practice. for those of you who are psychiatrists, can you lay out the advantages/disadvantages of each?? is it more stressful to work in a hospital? i figure the hours are less flexible, but is it a better option for someone that doesnt want to spend their entire life in the field? is there a big difference in the salary?

I'm guessing I'm one of the few psychiatrists who works exclusively inpatient (in the hospital). I work for the state, and the way it is set-up there are definite advantages. At least before I took over my current administrative role, I had a fixed schedule, 40 hour work week, and salaried for my time. There were opportunities for overtime "shifts" where I was paid for my time. I would say it is no more stressful than outpatient work, but there are definitely different types of stress.

I believe I am in the minority, working entirely inpatient. Most people I think do a combination of inpatient and outpatient work, or mostly, if not exclusively, outpatient work.

From what I have heard, for those that are in private practice and are mainly paid based on how much revenue they collect, outpatient work is more profitable than inpatient work. I don't know how true this actually is - it's just based on word-of-mouth.

I would think it is not much difference between inpatient and outpatient work regarding your "overhead" costs, as setting up a psychiatry practice is not too expensive. Often, you can join up with an existing group and they may guarantee you a salary up front for the first 6 months to 1 year, and then after that you work based on your collected revenue. Also, there are some clinics where they will pay you an hourly rate to see patients, and they cover your overhead. At most settings, you will probably need to pay for your own malpractice insurance, but some clinics / hospitals will pay that for you.

Doing outpatient work is probably more flexible regarding what hours you want to work in most circumstances. I think many people work outpatient clinics at multiple sites.

I can't really say if there is much difference in salary. I know that for the inpatient work people do for the state, they get compensated fairly well (in my opinion) - especially considering that malpractice is covered and the salaried position includes full benefits plus pension.

I think you'll really have to look at the specific opportunities available to you as you are finishing residency. I didn't consider starting my own solo practice, but I did interview with several private practices as well as academic and public positions. None of the positions would have required me to put money up front.

Let me know if you have more specific questions.

Having done exclusively inpatient work initially and now exclusively solo private practice for the last 12 years, I can tell you that the stresses are different but not necessarily greater for one than the other. For me the biggest difference is one of control: over hours, over bureaucracy. No boss. No job to lose. Many are more comfortable witha salary rather than income being whatever you generate. I think the payoff for that risk is often greater income. Private practice can be more isolating than the social environment of a hospital. Working in a hospital can be demoralizing if you are confronted by inadequate staffing, excessive paperwork, increasing patient loads, and marginalization of the psychiatrist into prescribing-only roles. Not that this is always the case, but it is not rare.

As to the debt issue, Dr. Admin is right. There is little overhead in setting up a private practice in psychiatry. It required no taking on of debt for me. You need an office, two chairs, and a telephone with voice mail. Ok, a malpractice policy too, but that's about it financially. So I don't think a future business ambition would argue for private practice vs. hospital work. But I wonder, if it is really your dream to run a company, have you asked yourself whether medical school and psychiatric training is the way to go?

is it difficult building up a clientele for a private practice?

I think it is hard to make a general statement about how difficult it is to build a practice. But building a referral network that works for you is a crucial issue in considering private practice. There are numerous factors to think about. Some are personal such as how you will connect with potential referral sources and what kind of patients and treatments you are interested in. Others relate to the larger community in which you will practice. Do people plan to use health insurance to pay for mental health care? What percentage of people have managed care policies that require a great deal of interaction with the insurance company? Do people see psychiatrists for psychotherapy in the community, or generally for medication treatment only?

Many psychiatrists do both private practice and salaried hospital work. I work just over 20 hours a week at the state psych hospital (just enough hours to get benefits), run a sleep lab/clinic for which I am a part owner, and go down to the state institution for the mentally retarded once a week as an independent contractor.
Michael Rack,MD