Any predictions as to why or when psychiatry is going to crash? Everyone is talking about a boom, bubble, and burst cycle.

[PikminOC]

You are a cog that can be replaced

Lots of new grads coming in with phat loans.

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[SmallBird]

You are a cog that can be replaced

Me specifically, or you have a more general point to make? I can be replaced, but not easily, and not cheaply, and I don't think I will be.

 

[PikminOC]

Me specifically, or you have a more general point to make? I can be replaced, but not easily, and not cheaply, and I don't think I will be.

All providers

 

[docksan]

That's a bit pessimistic. Psychiatrists are in giant demand and nobody wants the headache of having to hire a new physician, especially one that's established.

Granted if you work in an area that doesn't care about replacing you with a PA or NP, which is an even bigger headache waiting to happen for them, I guess you're expendable.

You sound burnt out.

 

[deleted456421]

As much as I decry midlevel independence, it's because I'm sick of seeing them harm patients while they march toward being considered as equals in the eyes of administrators and the public. However, I'm not really worried about psychiatry as a field over the next couple of decades, especially given growing demand for our services and a phenomenal job market that has only improved since the pandemic.

To contrast my employment opportunities and question my own beliefs about the sky falling, I know at least 5-6 NPs who returned to nursing because they couldn't find positions or would actually take pay-cuts as providers, despite the increased demand for mental health services,. Many systems don't seem keen about hiring those with online degrees or, from what I've heard on this forum, have even reversed their stances about employing midlevels. Several people responsible for hiring (including clinic directors who are LCSWs) have told me they'll hire any physician they can get and often feel resigned to hiring NPs as a last resort.

For myself, the pay and offers I've received have literally left me speechless at times. I only dreamt about making dermatology money while working 45-50 hrs weekly as a medical student, but I've had no problem earning over $400k/year with a very comfortable schedule (granted, I now believe salary surveys for dermatology and orthopedic surgeons must be lies).

I see half as many patients as my primary care and hospitalist colleagues but get paid better, all while exploring topics that really interest me. My own life and relationships have improved while learning various therapeutic techniques. Hopefully an oncologist doesn't get to say the same. Plus, I can still use my medical knowledge whenever it's relevant to patient care (I've already diagnosed two cases of NMS and truly believe I helped save their lives).

Sometimes I fall into the same trap as others and fantasize about my life as an engineer or programmer. I'd never make it in the C-suite, though, and can't imagine a job that would give me more satisfaction than the one I have, pay-wise or morally. I think I'd be miserable in any other field.

 

[FlowRate]

granted, I now believe salary surveys for dermatology and orthopedic surgeons must be lies

Open secret for a long time that private practice numbers are usually not well reflected in "salary" (employed job) surveys.

Sometimes I fall into the same trap as others and fantasize about my life as an engineer or programmer.

Same. Although, a little different than what you said, I think it's only a trap if it's a blind fantasy (no experience to validate, only looking at the prized ideal outcomes of those other fields.) I have an engineering undergrad degree and self-taught/published in machine learning during med school. I think I might have also been fulfilled/happy in those fields. However I don't think those fields would have been a big difference in terms of happiness/fulfillment. Especially not if I had gone down more of a typical engineer path out of undergrad.

 

[deleted456421]

Open secret for a long time that private practice numbers are usually not well reflected in "salary" (employed job) surveys.

Absolutely. I know at least one rural orthopod who makes >$1 million for 45 hrs weekly without call and at least 3-4 EM docs grossing >$600k in the same town. Psychiatry pulls rookie numbers.

 

[VA Hopeful Dr]

You are a cog that can be replaced

Eh, we're really not. The average time nationwide from posting a job to the new doctor starting is 18 months. And recruiting is expensive (usually 6 figures start to finish). Obvious this is location dependent (super popular areas probably don't take 18 months while rural SD likely takes longer).

 

[TexasPhysician]

Absolutely. I know at least one rural orthopod who makes >$1 million for 45 hrs weekly without call and at least 3-4 EM docs grossing >$600k in the same town. Psychiatry pulls rookie numbers.

Exactly. Derm in academics is $500k+ where I trained. Private is $1 mill+. Think about it though. My past derm would see me for about 5 min and used a scribe for notes. She signed the note leaving the room. Many biopsies can be just as fast. Even assuming no procedures, that could be 10+ E&M codes/hr. Other fields can’t match that.

The derm I had before that opened a “retirement practice” until he died worked PT for fun. Essentially $75 cash only for 10 minutes (2x the time now). Great guy. So even scaled back and avoiding insurance while not caring about $, he was at about $900k full-time equivalent.

I really enjoy what I do. According to salary surveys, I’m 90%ile in pay. I also make the least compared to my best 3 friends in on/gyn, IM, and ortho. This isn’t a big $ field. It’s plenty good enough for me though.

 

[calvnandhobbs68]

Exactly. Derm in academics is $500k+ where I trained. Private is $1 mill+. Think about it though. My past derm would see me for about 5 min and used a scribe for notes. She signed the note leaving the room. Many biopsies can be just as fast. Even assuming no procedures, that could be 10+ E&M codes/hr. Other fields can’t match that.

The derm I had before that opened a “retirement practice” until he died worked PT for fun. Essentially $75 cash only for 10 minutes (2x the time now). Great guy. So even scaled back and avoiding insurance while not caring about $, he was at about $900k full-time equivalent.

I really enjoy what I do. According to salary surveys, I’m 90%ile in pay. I also make the least compared to my best 3 friends in on/gyn, IM, and ortho. This isn’t a big $ field. It’s plenty good enough for me though.

Right literally a 10min "you've got acne, here's some minocycline/topical retinoid/etc, here's possible side effects, come back in x weeks so we can see if it got better " can be a 99204 (1 chronic condition with exacerbation/progression with prescription management). That's somewhere from 150-160 for most of my insurers. Derm is just pretty much an entirely visually oriented field, which means it can be done very quickly and relies a lot less (relatively) on patient report/history.

 

[FlowRate]

Absolutely. I know at least one rural orthopod who makes >$1 million for 45 hrs weekly without call and at least 3-4 EM docs grossing >$600k in the same town. Psychiatry pulls rookie numbers.

Hard to know how common higher-end incomes are in other specialties vs some of the high-end examples in psychiatry. Relatively common to hear about cash psych practices charging $250-$350 per hour. But I've also mentioned before the local psychiatrist who says she's full at $600+ per hour catering to people wooed by her "psychiatry/integrative holistic/functional medicine triple board certification." I'd imagine definitely easier to make higher end numbers in some other specialties, the derm example ITT being a good one.

 

[finalpsychyear]

Hard to know how common higher-end incomes are in other specialties vs some of the high-end examples in psychiatry. Relatively common to hear about cash psych practices charging $250-$350 per hour. But I've also mentioned before the local psychiatrist who says she's full at $600+ per hour catering to people wooed by her "psychiatry/integrative holistic/functional medicine triple board certification." I'd imagine definitely easier to make higher end numbers in some other specialties, the derm example ITT being a good one.

I do have some private accountants in my family since the late 80's who had many physicians under their practice. Salary data won't ever show you but quite common for ortho/surgical private practices to be netting 3-4 mill back in the good ole days and i am not talking inflation adjusted amounts. Maybe it is better that data is not advertised and long forgotten.. My best friend's dad was an ortho doc in the 90s and retired a few years ago. I visited them in their 5 mill house (friends wedding) in miami (1 of 3 houses) and he is quite forward with salaries of the good ole days saying what he would make in a 3-5 years then is what a career spine ortho would make now and generally sad for the state of medicine.

P.S. Don't try and calculate what 3-4 million in the early 90s would equate in today's money.

 

[painballer27]

I do have some private accountants in my family since the late 80's who had many physicians under their practice. Salary data won't ever show you but quite common for ortho/surgical private practices to be netting 3-4 mill back in the good ole days and i am not talking inflation adjusted amounts. Maybe it is better that data is not advertised and long forgotten.. My best friend's dad was an ortho doc in the 90s and retired a few years ago. I visited them in their 5 mill house (friends wedding) in miami (1 of 3 houses) and he is quite forward with salaries of the good ole days saying what he would make in a 3-5 years then is what a career spine ortho would make now and generally sad for the state of medicine.

P.S. Don't try and calculate what 3-4 million in the early 90s would equate in today's money.

Wow. 3 million in 1987 is equivalent to roughly 7.7 million in today's dollars. Could you imagine...

 

[docksan]

Wow. 3 million in 1987 is equivalent to roughly 7.7 million in today's dollars. Could you imagine...

Yes, it's what hospital administrators that don't make medical decisions make.

 

[Stagg737]

With dictation I've seen 3 new inpatients and 18 follow-ups and been out by 5 a couple of times. Literally is the difference between being out at 5 and out at 9 for me.

Lots of places have removed transcriptionists.

I'm curious, is your dictation system super accurate or do you just live with errors? I find dictation helpful for converting my sentence fragment hpi notes that I take during intakes into a cogent narrative but the errors are hard to catch/fix without slowing down so much that I might as well type.

Agree with MJ 100%. When I started using Dragon my weekend call shifts suddenly got much more manageable. I was able to cover our ~15 bed unit and have notes done by around 2pm as long as we didn't have a ton of new patients, where I was previously working through the whole call shift and sometimes late. Dragon has also has specialty-specific language, so it recognizes most meds and psych terms we use so only need a minute or two for editing once everything is dictated. I will add that this is using Epic as an EMR and that the EMR is just as important as actually dictating IMO. One of our locations for residency used Anasazi, and don't even get me started on CPRS. You can still dictate, but the EMR itself can be a game changer.

You are a cog that can be replaced

Then find a way to employ yourself or make yourself unique enough that finding a replacement cog that fits is almost impossible. Literally everyone and everything is replaceable depending on how you look at it, but there are plenty of things one can do to minimize that risk. I applied for several listed positions, but I'll ultimately be starting a position that I proposed to the hospital that a mid-level frankly could not do independently. I could certainly be replaced by other psychiatrists in the future, but the creation of the position involves certain steps that very few individuals could initiate and which most psychiatrists frankly don't want to do. It also has the potential to grow into something that would be both very beneficial to the hospital and a position where it would be relatively difficult to replace me.

While this position is fairly niche, it's not something that requires a particularly unique skillset. Most psychiatrists could set up a position like this if they wanted, the biggest requirement is just being able to recognize deficiencies or gaps in the system and proposing an effective way to fill them.

 

[clausewitz2]

Exactly. Derm in academics is $500k+ where I trained. Private is $1 mill+. Think about it though. My past derm would see me for about 5 min and used a scribe for notes. She signed the note leaving the room. Many biopsies can be just as fast. Even assuming no procedures, that could be 10+ E&M codes/hr. Other fields can’t match that.

I worked once with a dermatologist who for various OCD-related reasons accumulated a backlog of clinic notes for a three month span. When he was able to go back to tackle them, he told me that he had a little over 2000 notes to complete.