Medical Education US

Admin,
Thank you for the reply.
As I said, I am interested in providing therapy using both Psychotherapy and medicine (where necessary) to treat clients in a private practice, within California.

Would being a Psychiatrist be the advisable way to go, or would being a Psychotherapist be the preferable way?

Is the job market bright for Psychiatrists in private practice? Is the income better than being in a managed care setting?

Do M.D.'s have greater employment prospects in Psychiatry than do D.O.'s?

Do most Psychiatrists in a managed care setting provide therapy or more just prescribe medicine? What is the ratio e.g. 80/20, 60/40 on average?

Is there any training in psychotherapy provided to resident Psychiatrists?

What job trends do you see impacting Psychiatrists in the future such as in demographics of patients, trends in managed care, etc.?

I would like to have as much flexibility as possible in working in this career arena...and as always appreciate any answers...
Jesse


<edited title to better reflect content of message -
RM>

[ Edited by Admin on 2003/8/28 20:45 ]

I'm assuming you are the same person who posted this message asking for advice regarding psychiatry versus psychology.

Would being a Psychiatrist be the advisable way to go, or would being a Psychotherapist be the preferable way?

If you want to prescribe medications you would have to become a psychiatrist. In some states (like New Mexico), psychologists can prescribe, but that is really the exception. Also, in many states, nurse practicioners and physician's assistants can prescribe - some of these also do therapy and education is much shorter than medical school and residency. The majority of psychiatrists today, especially those more recently out of residency, seem to mostly do medication management.

Is the job market bright for Psychiatrists in private practice? Is the income better than being in a managed care setting?

In most areas, the market is pretty good for psychiatrists in private practice. I think you should read these definitions of managed care terms to better understand what managed care means. Private practice doctors can contract with managed care insurance plans (and many do), or doctors can choose to only see patients with non-managed care insurance (and some do), or doctors can choose to only accept payment at the time of service, and then patients have to submit their own claims, or not (a few do). In general, managed care contracts pay less than other types of insurance. There are some types of privately run (and publicly run) clinics that will salary a doctor to work a certain schedule, or pay them on an hourly basis. These practices though are almost all mediciation management clinics as it is not cost effective for a clinic to have it's psychiatrist providing the therapy (at least from the perspective of dollars per time spent - there have been some studies showing that psychiatrists who provide therapy and medication management are more effective than having a psychiatirst doing meds and a therapist doing therapy, but I've only skimmed these articles and it was a long time ago).

Do M.D.'s have greater employment prospects in Psychiatry than do D.O.'s?

Pretty much the same as far as I can tell for a career in psychiatrist. Most psychiatry residency programs are not that competitive, so DO's should be able to match at many programs. There were DO's in my residency program and they got good jobs and are good psychiatrists.

Do most Psychiatrists in a managed care setting provide therapy or more just prescribe medicine? What is the ratio e.g. 80/20, 60/40 on average?

See above. Especially in managed care settings I would guess psychiatrists do greater than 80% medication management. Although there are probably many psychiatrists who see patients through managed care contracts for medication management and then see private pay patients for therapy.

Is there any training in psychotherapy provided to resident Psychiatrists?

Yes. It is a requirement of the American College of Graduate Medical Education that all psychiatrists receive a specific amount of psychotherapy training. There is a large variance between residency programs, and some offer the bare minimum of psychotherapy training - and it may not even be that good of training.

What job trends do you see impacting Psychiatrists in the future such as in demographics of patients, trends in managed care, etc.?

This is really hard to say as trends in medicine seem to be fairly short-lived. My guess is that psychiatric practice will continue to treat the same general group of patients, but that treatments have the potential to become radically different over the next 10-20 years as the genetic basis of disease is better understood. I don't mean just the hereditary nature of illness, but the genetic codes that underly illnesses. This area is still rapidly developing and there are some new technologies which have the potential to radically change the way we understand much of the medical world. I digress (again)...

Regarding trends in managed care, I believe that the pendulum is swinging away from managed care. From what I've heard, though, California is generally 5 years ahead of the rest of the country with trends. Whatever is going on in California will probably hit the mid-west in a few years.

I think that psychoanalytic therapy is probably going to continue to shrink (no pun intended). Psychiatrists are likely to increasingly focus on medication management and ECT, especially as these treatments continue to improve. There is always a need for therapy skills, even in medication management, but the purposes of the visit won't be to provide therapy.

I would like to have as much flexibility as possible in working in this career arena...and as always appreciate any answers...

A psychiatrist has the most flexibility in the sense that they can prescribe medications. However, the training is VASTLY different and VASTLY more challenging (physically, cognitively, emotionally, and financially) than going to graduate school for psychology. I'm not saying graduate school for psychology is easy - it's not as far as I can tell. It's just medical school is an entirely different level of pain that no one can understand unless they've done it. While the TV show ER is great and fairly close in many aspects (at least the one season I had time to watch around 6 or 7 years ago) it only scratches the surface of the real stress involved in being a medical student / resident.

If I knew that I wanted to be a therapist at the start, I wouldn't go to medical school. (By the way - I'm not currently practicing proving therapy at this time, at least not in the typical sense).

Admin,

Thank you for your time, it seems the lot of Psychiatry involves medication management. It seems that it would be cheaper for hospitals and such to employ assistants to prescribe medication.
My questions are:
#1 Aside from prescribing medicine, are there any other job aspects of being a Psychiatrist ? or is most of the day spent managing medication?
#2 How does private practice differ in the practice of Psychiatry itself versus working in let's say a hospital? Is there more one on one time with clients? Is therapy more extensive in private practice?
#3 Is pay better in private practice versus in a hospital?
#4 Is there any common marketing way of bringing clients into one's private practice?

My reference for private practice is envisioning a scenario such as that of the Sopranos where Dr. Melfi counsels patients.

#5 Is that a realistic portrayal of private practice for Psychiatrists?

#6 Is there a genuine public need to have individuals who provide therapy as well as medication versus referring patients to one and the other for the separate functions?

#7 Is it realistic to think that would could earn a good living and help people at the same time by having a private practice and working part time for a hospital/clinic?

Thank you for all responses, and if there's any way for me to contribute to this site, let me know...
Jesse

#1 Aside from prescribing medicine, are there any other job aspects of being a Psychiatrist ? or is most of the day spent managing medication?

It completely depends on the way the practice is set-up or what the person chooses to do. For many psychiatrists, they are the owner or a partner in a practice. This means there are many business aspects of managing their business. Some psychiatrists will hire practice managers to do this for them or do it themselves. To clarify, a part of prescribing medications effectively involves accurately assessing patients. This means do initial psychiatric assessments as well as follow-up assessments to determine treatment. Involved with this comes paperwork to document assessments and treatment plans. Most psychiatrists have admitting priviledges at a hospital. Doctors will see their hospitalized patients daily typically. Many will also be in some sort of "on-call" rotation to see emergency patients after hours and determine if they need to be hospalized or recommend treatment short of hospitalization. Academic psychiatrists may also be involved in research and lecturing students and residents. Forensic psychiatrists may do forensic evaluations and have to give court testimony. Consultation-liaison psychiatrists (in the process of being renamed psychosomatic medicine doctors) assess medically ill patients and recommend treatments and educate the referring physicians. There is really a large variety possible, but I think the majority of private practice psychiatrists spend the majority of their time doing evaluations and medication management.

#2 How does private practice differ in the practice of Psychiatry itself versus working in let's say a hospital? Is there more one on one time with clients? Is therapy more extensive in private practice?

It depends on how you practice. Typically dealing with hospitalized patients is a part of doing outpatient psychiatry. I am actually only working doing inpatient psychiatry at this point, but I am in a public health setting which differs considerably from private hospitals. Each psychiatrist chooses how they want to structure their time. I have not had to deal with insurance companies since residency, but I would guess that an insurance company is going to pay a psychiatrist the same amount whether he/she spends 5 minutes with the patient or 90 minutes (aside from an initial assessment, which they will probably pay you the same amount whether you spend 30 minutes or 90 minutes). I actually think billing codes are broken down into 20 or 30 minute blocks, but an insurance company probably won't approve a psychiatrist spending more than a certain amount of time for particular problems, although I think you get paid different amounts based on complexity levels, as long as you justify the complexity level you bill for. It all seems like a pain to me, so I'm happy to be in a state system where I don't have to worry about billing or documentation requirements related to insurance reimbursement.

#3 Is pay better in private practice versus in a hospital?

There are private hospitals, and private parctice doctors typically follow their patients when they need to be hospitalized. From what I have heard from friends who are in private practice, seeing the hospitalized patients does not pay as well as seeing outpatients. There are niches, though, that can probably be fairly profitable, such as geriatric psychiatry where you may have many nursing home patients or patients who require ECT, which I have heard can pay well. For me, working in a state hospital, I think I get compensated fairly at this time.

#4 Is there any common marketing way of bringing clients into one's private practice?

Word of mouth is the main way. Medical doctors will refer their patients to you. Or you may be the doctor covering calls for an emergency room and see the patients and then have them see you in private practice. I can't remember seeing a psychiatrist advertise, aside from maybe a yellow-pages listing.

My reference for private practice is envisioning a scenario such as that of the Sopranos where Dr. Melfi counsels patients.

#5 Is that a realistic portrayal of private practice for Psychiatrists?

I've never seen the Sopranos so I can't comment. My guess is that any psychiatrist who is portrayed as providing mostly therapy is atypical for today's psychiatrists. Yes, there are some who do primary therapy and psychoanalysis. You would have to be very good to get clients, as I have only heard of one situation where insurance paid for analysis (and I'm amazed at even that). Again, I am not trained in analysis, and I don't much contact with analysts so my perspective maybe be very biased. You may want to seek out some other opinions from analysts (many of whom are psychologists).

#6 Is there a genuine public need to have individuals who provide therapy as well as medication versus referring patients to one and the other for the separate functions?

Whether there is a public need or not, if it doesn't pay, you won't find too many people doing it. I personally think there are many people who would benefit from their psychiatrist providing therapy for them. Of course, I am biased, but doctors in general have some common strengths, and many people who choose psychiatry make excellent therapists. While it may seem greedy that these doctors choose to do more medication management than therapy because of financial reasons, these monetary differences are not small. The difference between 15 minute med checks and 30 minute med checks / thearpy is probably close to doubling your income. This becomes more understandable when put in the context that medical school is very (VERY) expensive. If you are a talented therapist with wealthy clients, they might pay you cash for your time. I don't know many people who can make a living doing this. And I can only imagine how expensive it is to get trained in analysis - which requires undergoing your own analysis - seeing an analyst several days a week for years. Some people do it though. You may want to contact one of the psychoanalytic organizations for information and talk to someone who practices analysis. It seems like that is more the type of therapy you are considering.

#7 Is it realistic to think that would could earn a good living and help people at the same time by having a private practice and working part time for a hospital/clinic?

Yes. This is actually how most psychiatrists work.

Thank you for all responses, and if there's any way for me to contribute to this site, let me know...

I think you already have

Hello Admin,
It seems additional questions arise in my mind as we engage in these sessions.
Additionally,

#1 Is it safe to assume that a large majority of private practice psychiatrists see a large majority of patients paying through insurance providers? Do insurance providers pay Psychiatrists strictly for the medication management services they provide?

#2 Do most private psychiatrists see patients strictly for medication management and then refer them to a therapist for "talking therapy?"

#3 Do most Private Psychiatrists have patients on a "pay as you go" payment plan or do most private psychiatrists work with patients through insurance plans?

#4 Is it realistic that a private psychiatrist would see a patient and provide both some sort of therapy along with medication management?

#5 Could you describe your work as a Psychiatrist in a public health setting? How does it differ from private setting? Are there more professional pressures?

#6 Do Psychiatrists have a lot of flexibility in
determining their work schedules, meaning are psychiatrists pretty much their own bosses? What types of constraints would they work under in a private setting/public setting?

As you may tell, my goal would be to work as a private psychiatrist providing both medicine and therapy to treat a patient.

#7 Do you see this as a viable professional option for a Psychiatrist? Is there an opportunity here to earn a good living? What is your take on this market (if one exists)? Do you see this as something viable given current trends in Psychiatry?
An elaborate answer here would really help me....

As always, thank you for your time...
Jesse

#1 Is it safe to assume that a large majority of private practice psychiatrists see a large majority of patients paying through insurance providers? Do insurance providers pay Psychiatrists strictly for the medication management services they provide?

Most psychiatrists in private practice see patients who have private insurance. Some will also see many patients that receive medicare or other forms of public aid. From what I remember, insurance companies base their reimbursement rates on codes similar to what medicare sets. Basically there are different billing codes for different services provided and different levels of complexity. I think there are some billing codes for psychotherapy, some for psychotherapy plus meds, and some for primarily meds. There are different documentation requirements in order to bill for different services provided. Again, as I don't have to deal with insurance companies, I really don't get involved with it.

#2 Do most private psychiatrists see patients strictly for medication management and then refer them to a therapist for "talking therapy?"

I would think the majority do, but some will see certain patients for therapy, so that a part of their practice still involves providing therapy.

#3 Do most Private Psychiatrists have patients on a "pay as you go" payment plan or do most private psychiatrists work with patients through insurance plans?

I would think most work through insurance plans.

#4 Is it realistic that a private psychiatrist would see a patient and provide both some sort of therapy along with medication management?

Yes. But the majority of psychiatrists probably have only a small number of patients (if any) that they see for therapy in addition to meds.

#5 Could you describe your work as a Psychiatrist in a public health setting? How does it differ from private setting? Are there more professional pressures?

I only do inpatient psychiatry. The hospital I work at is for people who don't have insurance or any other type of public funding. Because I'm now working within the city of Chicago, I see a relatively large homeless population. My work is mostly with stabilizing whatever the main problem is, so that the person is well enough to function outside of a hospital and can then participate in outpatient treatment. I actually see people with a large variety of problems - from some relatively wealthy people who just happen to be out of work, or took on way too much debt to the poorest people with the most severe illnesses. Because I don't have to deal with insurance companies, I am given a lot of freedom with deciding how long I think the patient needs to stay. This is very different than private practice where an insurance company will have fairly strict criteria, and even if you feel the patient would benefit from some more time in the hospital, the insurance company will make it clear they will not reimburse you for those days. Also, I am salaried, with benefits, and work a fairly fixed schedule. I think it's possible to make quite a bit more money in private practice, and there is more control over deciding what types of patients you choose to see. I'm not sure what you mean by asking about professional pressures - in private practice, I'd have much more administrative duties by coordinating and supervising other employees in the practice. In many ways I have a lot less pressure because I don't have to take call or worry about my patient's calling me in the middle of the night with emergencies. I do see some very sick people with very poor prognoses though - which is much less common in private practice.

#6 Do Psychiatrists have a lot of flexibility in
determining their work schedules, meaning are psychiatrists pretty much their own bosses? What types of constraints would they work under in a private setting/public setting?

In private practice, you can really pretty much set your own schedule. You're pretty much your own boss, but if you are in a group then the partners make the main decisions as far as I can tell. In the public setting, you will always have a boss, no matter what level you are at. In private practice you can set your own hours (unless you join a group, and different groups will provide different benefits) but if you take time off, you don't make any money. For me, I am salaried to work 40 hours a week. I get so many vacation days, sick days, insurance benefits, pension dollars, etc.

As you may tell, my goal would be to work as a private psychiatrist providing both medicine and therapy to treat a patient.

#7 Do you see this as a viable professional option for a Psychiatrist? Is there an opportunity here to earn a good living? What is your take on this market (if one exists)? Do you see this as something viable given current trends in Psychiatry?
An elaborate answer here would really help me....

It is certainly a viable option for a psychiatrist. Regarding a "good living" it depends on what you consider a good living. Also, you had mentioned in your very first message that you were an "older student". Depending on how much older, and your current financial situation, you are probably looking at taking on quite a bit of debt to go to medical school (assuming you meet all the requirements to get accepted). Medical school is extremely expensive. Then you would have the 4 years of residency for psychiatry, which can be extremely brutal for very little pay. And then you have all of your debt to repay when you are trying to start out your practice. I think you'll never really need to worry about being out of a job though. There will always be people for psychiatrists to treat. There will always be people who will want to see a good therapist (but you don't need to be a psychiatrist to be a good therapist). There have been trends where people thought that more of the prescribing of medications would go to primary care doctors, but I think things are actually moving away from that in some ways. Primary care doctors still prescribe way more antidepressants than all psychiatrists combined, but for anything beyond basic depression and anxiety disorders, it is pretty rare to find a primary care doctor who wants to treat it themselves. And with all of the new medications coming out, it's almost impossible for a primary care doctor to keep them all straight.

I am a psychiatrist in private practice. Just to provide another perspective to that stated above, I see 70% of clients for therapy or therapy plus medication and 30% for medication only. i have no involvement in managed care, no direct dealings with insurance companies (the patient himself submits my bill, if he chooses, for reimbursement) and am paid by my patients at the time of service. The work is rewarding, lucrative, and administratively uncomplicated.

Hello, Psychiatrist-In-Private-Practice... thanks for your post.

A barrage of questions, if I may:

How does your office avoid the managed care aspect? Do you lose patients because of your decision not to bill insurance companies? In what part of the country do you practice? How big is your office staff? How do you divide up your time between patients? Do the therapy+meds cohort get 50 minutes, and the meds-only cohort get half that? Do you have more than one psychiatrist in your office?

I would love to get more information on your practice. Thanks!

Happy to oblige. I am in solo private practice. My practice is set up for maximum convenience for me, efficiency of time spent in the office, and for the provision of high quality care. I have no office staff. I show up, see my patients, return my phone calls, and leave. I do my own scheduling, and my answering machine answers my phone. Once a month I sit down for an hour and hand-write bills to give to my patients; for those who submit them for reimbursement I include CPT and Diagnostic codes. I guess I lose some patients due to not being part of insurance plans, but my practice is close to full. In the long run I am better off without the loss of control and the requirements to submit information, the time required, etc. that go along with insurance participation. Also, I don't need to see as many patients as I otherwise would because I am not limited to the reimbursement schedule determined by the insurance company, but rather set my own fees which are higher in general. How do I avoid managed care? Well, I started out with a fair amount of it, but got very frustrated with it. I decided to resign from all panels, and to allow my practice to grow more slowly. Over time (I've been in full-time Pr. Practice for 10 years) I built a good referral network not based on managed care. I have two offices: I spend 2 days a week in Manhattan, and two days a week in an office near my home in Westchester County NY. Perhaps this would be more difficult in some areas of the country, but I do have colleagues in other cities who do the same thing. My therapy sessions are generally 45 minutes in length. Medication only visits are either 30 minutes or 45 minutes depending on the complexity, time required, as well as patient preference. Hope that helps!

One interesting thing you said was that if you knew you wanted to do therapy, you wouldnt go to medical school. Is it wrong for me to think that I want to do therapy but also want a more stable job (financially) and so me school would be a better route? Can't I go to a stronger therapy-based residency program after med school and then do 50-50 therapy-medication? Or is that too much of a fantasy?

You misquoted me - I said if I knew at the start that I wanted to be a "therapist" I would not have gone to medical school; meaning, if I knew I only wanted to provide therapy, and not prescribe medications.

It is not a fantasy for a psychiatrist to have a 50-50 practice between therapy and medication, especially if you got to a residency program that has a strong psychotherapy training component.

I'm not sure who you are addressing when you mention the person who wouldn't have gone to medical school if he wanted to do therapy. But for me, I see roughly 70% of my patients for therapy and /or therapy plus medication. I am pleased to be able to do the combination: Both interest me and are gratifying, and my private practice is more secure and more robust in my having the option to do both and to accept referrals of patiients who have a wider variety of needed therapeutic modalities. If not for that flexibility, I'd have to refer out a significant portion of the referrals that come to me. And, in my opinion, if not for the combination of approaches I practice -- if I had to forego one -- I would be missing a major part of what I enjoy about my work.

Oh, and also: I did benefit from training at a program that provided a strong background in psychotherapy theory and technique. It helps.

Hey pyschiatrist in private practice. I am also in the NYC area, do you hve any contact info (email, yahoo, aim) in which I could ask you some questions. I am considering pyschiatry as a possible profession to get into.

Hi. I'd be happy to answer any questions I can, but I want to respect Admin' suggestion that questions be posted here so that all can get the benefit of the discussion. I'd be happy to respond here if you let me know what you'd like me to address.