Dark Future 'What if'

[Sushirolls]

Let's imagine the day has come, where we are in the same position as EM and the job market is plummeting. The storm clouds are no longer on the horizon by the torrential rain is here.

The ranks of midlevels have surged. The number or residencies have surged and every for profit HCA and similar for profit psych/addiction hospital now has a residency. Newly minted psychiatrists are starting to be jobless post residency. Psychiatrists are clamoring to get non-profit hospital jobs doing C/L and ED coverage for nights/weekends with no increase of pay for night work. The outpatient market is saturated and all commercial insurance now pay well below medicare rates. The VA is saturated and no interest in further expansions. Prison jobs only have openings after the previous person takes the fall for their legal issues. Big Box shops further worsen the issue by mandating the 15min med check again.

Private practice is saturated by those who already have established practices and built up their reputations or by the upstarts who know best how to say, 'Yes!' to those stimulants and benzos. Psychiatrists are applying for Psychologist only postings to do therapy and even get these positions at times.

What do you do? Where do you go? What's your plan B once the blight of the Emergency Physician comes to our peaceful grove?

---

Members don't see this ad.

 

[Roxas]

In this case, I imagine sitting on my yacht ruminating on the downfall of our field. Am I going to be thinking about how much money I have? No. I'm going to be thinking about how many friends I have, and my children, and my comedy albums. I mean, I have a yacht, so I obviously did pretty well money-wise.

 

[wolfvgang22]

In this case, I imagine sitting on my yacht ruminating on the downfall of our field. Am I going to be thinking about how much money I have? No. I'm going to be thinking about how many friends I have, and my children, and my comedy albums. I mean, I have a yacht, so I obviously did pretty well money-wise.

My yacht has paddles, two seats and Pabst blue ribbon.

 

[Jules A]

My yacht has paddles, two seats and Pabst blue ribbon.

Then you my friend will be content regardless of the external forces. Good spot to be in.

 

[allantois]

Yawn

 

[watto]

Enjoy life as an expert witness for malpractice case prosecuting attorneys.

 

[Monocles]

Psychiatrists are clamoring to get ... ED coverage for nights/weekends with no increase of pay for night work.

I like ED so this is actually not a negative for me, lol.

Hopefully this worse-case scenario is at least a decade away so I'll have reached my FIRE goals by then. If not then may the gods help us all.

 

[birchswing]

I think there's a field that deals with negative, what-if thinking.

I can get you in touch with an NP that works in that field if you need some help.

 

[Sushirolls]

The 'what if' scenario is possible and very likely coming for Psychiatry, albeit years from now, but its coming. Folly to not observe the trends of what's happening to Emergency Medicine, Pathology, Radiation Oncology - all separate and unique fields - and believe that Psychiatry is immune.

If its more palatable for some, another way to phrase this 'what if' would simply be to ask, what would you do if you couldn't practice Psychiatry tomorrow?

I for one would be a goat farmer, with goal of 100 plus bee hives, acreage to grow enough hay for the goats, emphasis on meat varieties. Possibly consider milk varieties to largely produce ghee and lesser so soaps. Lots of tractor seat time, and fair sized garden to reduce purchases from grocery stores. Seasonally I'd chase after Spring Bear, Spring Turkey, and enjoy the pursuits of Elk and Deer each fall. Strive towards mastering wild game cuisines based on traditional world cuisines with my own little adjustments. Enjoy the seasonal burning of brush piles each Spring. Ferment juice wines from harvested fruits each fall, mostly apple. Grow my own select hops to create my own IPA variety. And of course use the honey to master baklava!

Income source: goat meat, honey, Ghee, soaps, and other smaller produce products; if acreage permits hay surplus

 

[wolfvgang22]

I'd probably teach if still possible.

 

[ksharp33]

At that point, I would consider switching to radiology. At least they are more protected from midlevel encroachment. If anything, midlevels will always keep them in business by ordering imaging for anything and everything.

 

[Stagg737]

I'd probably teach if still possible.

This would probably be my path as well. Or possibly find a primarily English-speaking country abroad and do that. I actually looked into moving to Australia at one point several years ago and would consider that again.

I would hope that I'd have enough in retirement to mostly FIRE at that point if necessary. If that were the case I wouldn't mind doing personal training or coaching at the high school or college level. Worst came to worst, "life coaching" seems like it would be possible if I felt like selling a part of my soul. I've got several patients who have started their own life coaching companies and I'd imagine having actual experience with therapy and psychiatry would probably be beneficial. I'd probably hate that though, lol.

 

[crossled]

Psychiatry seems the most vulnerable to this to me out of the remaining specialities because:

1) There are such low overhead costs, if psychologists, and psychotherapists in addition to the midlevels that want to be able to prescribe medication, were able to do so, it would be really hard for psychiatrists.
2) Psychiatry seems like it still is looked down upon by the rest of medicine and is overlooked. When it comes to allocating resources, psych will be the first to be overlooked.
3) Psych is getting more competitive. There is projected to be an oversupply of CAP by 2030. P

 

[Sushirolls]

In this case, I imagine sitting on my yacht ruminating on the downfall of our field. Am I going to be thinking about how much money I have? No. I'm going to be thinking about how many friends I have, and my children, and my comedy albums. I mean, I have a yacht, so I obviously did pretty well money-wise.

Do you mean a boat like this?

 

[allantois]

There's people who see opportunity, and then there's people for whom the sky is falling. Both of the psychiatrists I worked for (I am a psych PA) are multi-millionaires. If you cannot make it as a psychiatrist, that's on you not wanting to adapt to modern trends in healthcare; not because there's an oversaturation of providers (there never will be in psych; and there isn't in anesthesia either). See how you can provide services for more patients; not limit patients access to healthcare

 

[Psychresy]

Still in residency. This scares me.

 

[Monocles]

3) Psych is getting more competitive. There is projected to be an oversupply of CAP by 2030. P

Wait seriously? Can you show a source of this?

 

[Ole_Toe]

Still in residency. This scares me.

Honestly, I haven't seen anyone on these forums complaining about finding a job after residency, even in desirable areas. There is the potential for a worse job market in 10 years for sure, but there's also potential for a really strong job market with more money invested into mental health services from the states and feds, good reimbursement, and more roles for psychiatrists both in employed and private practice.

 

[splik]

This is the government's latest projections as mandated by the 21st Century Cures Act. It's obviously based on modeling with a number of assumptions but you can see by 2030 they expect there to be a shortage of over 12000 psychiatrists but a glut of child psychiatrists. This is based on the number of adult psychiatrists retiring/dying being much greater than for child psych, and the number of newly trained child psychiatrists entering the workforce far outstripping attrition. Either way, these numbers do not suggest anything to worry about right now. The numbers of also show there will be a glut of NPs, but that won't make up for the shortfall in psychiatrists. However these numbers are being used to massively push through expansions in numbers of NPs.

My recommendations for those in psychiatry is to specialize, and to diversify your skill set. Areas for growth include geriatrics, addictions, neuropsychiatry, transgender medicine, and hospice and palliative medicine. Specializing does not necessarily require, but could including fellowship training and/or obtaining board certification. Leadership skills, psychotherapy skills, confidence working with complex medical issues, ethical issues, medicolegal issues will be very helpful.

While the sky is not falling, it is good idea to diversify your skillset both within and outside of medicine. You should assume you could lose your license tomorrow, because you could.

 

[Splenda88]

I am not in psych but anyone who is finishing residency right now should make a 10-year plan to be financially independent. Who would have thought that it would be hard to find a hospitalist job in city/suburbs? In one of my interviews, the CEO told me straight that he is hiring some NP/PA instead of having all MD/DO.

 

[Stagg737]

Psychiatry seems the most vulnerable to this to me out of the remaining specialities because:

1) There are such low overhead costs, if psychologists, and psychotherapists in addition to the midlevels that want to be able to prescribe medication, were able to do so, it would be really hard for psychiatrists.
2) Psychiatry seems like it still is looked down upon by the rest of medicine and is overlooked. When it comes to allocating resources, psych will be the first to be overlooked.
3) Psych is getting more competitive. There is projected to be an oversupply of CAP by 2030. P

Eh, as others have said the demand is still very high, probably higher than ever. The supply/demand aspect isn't all that concerning for the near future (20 years down the road may be a different story). The part about psych being looked down upon is true in some ways, but we'd be sorely missed in many others as evidenced by the large number of terrible consults (SI that isn't real SI, general agitation/delirium, basic capacity evals) that are prevalent in pretty much every health system.

If the mid-levels you named wanted to prescribe meds, I think it would make minimal difference. Treating basic problems would likely take burden off of PCPs instead of hurting psychiatrists. I've found the professions you mentioned to be almost uniformly awful at choosing the right meds and they frequently do more harm than good. Same goes for their diagnostic skills (with the exception of psychologists there). Sometimes I feel like half my job is telling patients who saw an NP that they're not actually bipolar or getting them off of some ridiculous med combo that involves multiple meds from the same class and at least one class of controlled substance.

 

[MacDonaldTriad]

We are building a lot of C&A fellowships, but the ones we have already don't fill. Building more is unlike to glut the market any time soon. Our building more general programs probably threaten NPs more than us. Many employers start with MD positions and then give up and hire NPs.

 

[Monocles]

View attachment 335603

As a data nerd I *REALLY* love this table. Only thing I wish they had an updated model accounting for covid related increase in MH needs, esp in kids and adolescents. If I had to guess the projected demand for child psychiatrists in 2030 is probably higher than 9190, lol.

Honestly, I haven't seen anyone on these forums complaining about finding a job after residency, even in desirable areas. There is the potential for a worse job market in 10 years for sure, but there's also potential for a really strong job market with more money invested into mental health services from the states and feds, good reimbursement, and more roles for psychiatrists both in employed and private practice.

100% this. I live in Boston and there are recruiters bombarding me weekly via phone calls, text messages, email, etc that I just ignore all communications now lol. (My information is NOT posted publicly anywhere so I don't know how they have it!) Perhaps I'll eat my words some day but the way the market is I cannot imagine a world where psychiatrists are not in high demand.

Anytime I see other specialties panic over midlevel encroachment I just secretly [laugh in psychiatry] to myself...

 

[Stagg737]

100% this. I live in Boston and there are recruiters bombarding me weekly via phone calls, text messages, email, etc that I just ignore all communications now lol. (My information is NOT posted publicly anywhere so I don't know how they have it!) Perhaps I'll eat my words some day but the way the market is I cannot imagine a world where psychiatrists are not in high demand.

Anytime I see other specialties panic over midlevel encroachment I just secretly [laugh in psychiatry] to myself...

Also agree. I went to one job fair and I now get 5-10 offers/recruiter calls per week. My parents have actually started getting calls asking to speak to me about locums positions (and that hasn't been my permanent address for almost 10 years). Even before that I was getting contacted 5-10x per month about positions. The pay may not always be where it's at now, but I think we're going to have job security for a long time.

 

[FlowRate]

The numbers splik posted are pretty convincing that this is not likely to happen. If anything, will probably have more bargaining power/market power for private practice.

But if it did I have a pretty diverse skillset and appropriate brands on my CV that I could brush up and find reasonable gainful employment whether it's through consulting, data science/health tech, or whatever.

 

[TexasPhysician]

Demand is high and will likely continue to be high for years. I’ll probably be cutting back even further clinically in the next 10 years, and I won’t be surprised if many of us here join me.

In looking at my medical school, the majority of staff have retired. In looking at my residency (less than 8 years out), the majority have retired. So much changes that it is hard to predict a decade from now.

 

[comp1]

I'd probably teach too, maybe research, but I think it's right to remember that this is...dystopian. A comet could also hit the planet tomorrow. This is not realistic or something to be scaring the residents with. Jobs are more than plentiful for all and literally no one is actually forecasting the OP's story. Even ED physicians are still going to be able to afford their mortgages and student loans. Also, their issues are a lot more complex than "NPs took our jobs." I'm not even sure that's a major factor.

 

[Merovinge]

View attachment 335603
You should assume you could lose your license tomorrow, because you could.

Love the chart, I had seen it once before but thank you for reposting. Strongly disagree with this quotation however. The odds of losing your license as a psychiatrist that is not committing outright fraud is almost certainly less than many other events. While one should insure against catastrophe if someone is depending on you via life/disability insurance, I also don't see anyone recommending assuming that you will die in a fatal car accident or get cancer when you are 40. As we all know so well, there's a real risk/benefit to what we spend cognitive energy worrying about and losing a medical license in this country would definitely not be on my recommended list for that.

 

[LimpSpatula]

I'd probably teach too, maybe research, but I think it's right to remember that this is...dystopian. A comet could also hit the planet tomorrow. This is not realistic or something to be scaring the residents with. Jobs are more than plentiful for all and literally no one is actually forecasting the OP's story. Even ED physicians are still going to be able to afford their mortgages and student loans. Also, their issues are a lot more complex than "NPs took our jobs." I'm not even sure that's a major factor.

The issue is that medicine is a business, and doctors aren't business men. Nurses certainly are and kudos to the rise of their profession. Maybe that aspect wouldn't have even reached the mobile -lobotomy-esque crescendo it did. Just look at recent events of our 2 professions. Nurses getting independent practice rights, stronger unions to sizeable minority of the public calling our most respected an idiot and ignoring his pleas during the pandemic.

We need grass roots movement. If the above happened, I'd feed my family. As it is, I have no false sense of belief that we are somehow in the right here. So I'd stay within the bounds of the law and continue to do whatever psychiatry business is available.

 

[Monocles]

The issue is that medicine is a business, and doctors aren't business men. Nurses certainly are and kudos to the rise of their profession. Perhaps the doctors should have been more collaborative from the start instead of stroking their own masculine ego, pillaging our capitalistic system. Maybe that aspect wouldn't have even reached the mobile -lobotomy-esque crescendo it did. Just look at recent events of our 2 professions. Nurses getting independent practice rights, stronger unions to sizeable minority of the public calling our most respected an idiot and ignoring his pleas during the pandemic.

We need grass roots movement. If the above happened, I'd feed my family. As it is, I have no false sense of belief that we are somehow in the right here. So I'd stay within the bounds of the law and continue to do whatever psychiatry business is available.

I kinda agree with this take (if I am interpreting it correctly). Doctors don't have to be businessmen, most physicians have such a criminally poor understanding of basic rational economics and financial literacy that "Big Medicine™" is making hand over fist on physicians labour and taking advantage of the profession.

The way to fight it, IMO is to talk about the financial and reimbursement aspect more - so that psychiatrists can understand their true market value, and then collectively negotiate (whether through unions, groups, etc). We should all challenge the assumption that talking about pay and money as physicians is taboo.

Honestly I think nurses and mid-level practitioners are getting it right in that perspective.

 

[calvnandhobbs68]

I agree that the issues with EM are a lot more complex than just NPs taking positions, although that plays a part in it. I won’t restate what I’ve said in other threads but there were many factors in play there including the rapid rise of residency spots (driven by many for profit entities who saw residencies as money makers), the lack of any real autonomy in EM (there’s essentially no way to separate yourself from a hospital/large group), lack of a loyal patient base (nobody cares or has any control over who they see in an ER), consolidation in the sector and rapid midlevels use. There were also lots of little urgent cares/low census ERs that went under or were consolidated during covid.

Anesthesia has been crying about CRNAs taking their jobs for over 20 years now (this had been a thing when I started med school....) and there still aren’t widespread problems with anesthesia attendings making less than 300k a year...they were just sad they can’t waltz into a job making 500kz

 

[Candidate2017]

What do you do? Where do you go? What's your plan B once the blight of the Emergency Physician comes to our peaceful grove?

My Plan B is to practice non-evidence based, cash psychiatry. The wackier, the better. Think astrologically based, chakra, spirit animal cleanses that correspond to phrenology types. I will earn triple the average psychiatrist income, for half the work.

Actually, that seems like a good Plan A.

 

[Candidate2017]

Psychiatry seems the most vulnerable to this to me out of the remaining specialities because:

1) There are such low overhead costs, if psychologists, and psychotherapists in addition to the midlevels that want to be able to prescribe medication, were able to do so, it would be really hard for psychiatrists.
2) Psychiatry seems like it still is looked down upon by the rest of medicine and is overlooked. When it comes to allocating resources, psych will be the first to be overlooked.
3) Psych is getting more competitive. There is projected to be an oversupply of CAP by 2030. P

1. PhDs don't want to prescribe. They have a good thing going and are smart enough to avoid the heavy burden of a script pad. But SW therapists, I'm pretty sure would love to prescribe Adderall and Latuda like candy. Let them. They'd quickly be in over their heads in a poop storm, even worse than midlevels.

2. "Looking down" on psych is mostly the province of med student gunners, who don't have much data on specialties other than income reports that skew psychiatry lower due our preference for working less than full time work. Allocation of resources is actually just the government looking at which specialty is billing the most, and slashing those reimbursements.

3. No one wants to do child psych, not even the child psych people. You can't find anyone seeing kids for 40 hours a week. The full timers split time seeing kids and adult 50/50. But almost all go pure part time mommy track.

 

[Splenda88]

I kinda agree with this take (if I am interpreting it correctly). Doctors don't have to be businessmen, most physicians have such a criminally poor understanding of basic rational economics and financial literacy that "Big Medicine™" is making hand over fist on physicians labour and taking advantage of the profession.

The way to fight it, IMO is to talk about the financial and reimbursement aspect more - so that psychiatrists can understand their true market value, and then collectively negotiate (whether through unions, groups, etc). We should all challenge the assumption that talking about pay and money as physicians is taboo.

Honestly I think nurses and mid-level practitioners are getting it right in that perspective.

The whole thing stinks. Being on the job market right now has opened my eyes about the business of medicine.

For instance, one hospitalist job would offer 320k/yr for 16-18 patient encounters while another that is 5 miles away would offer 260k/yr for 20-22 patients. Benefits (401k, Medical insurance, etc...) of the former are even better. Patient population is somewhat similar. How do you even reconcile that?

 

[Sushirolls]

You don't reconcile it, the employer pockets it, 'nough said.

 

[birchswing]

The 'what if' scenario is possible and very likely coming for Psychiatry, albeit years from now, but its coming. Folly to not observe the trends of what's happening to Emergency Medicine, Pathology, Radiation Oncology - all separate and unique fields - and believe that Psychiatry is immune.

If its more palatable for some, another way to phrase this 'what if' would simply be to ask, what would you do if you couldn't practice Psychiatry tomorrow?

I for one would be a goat farmer, with goal of 100 plus bee hives, acreage to grow enough hay for the goats, emphasis on meat varieties. Possibly consider milk varieties to largely produce ghee and lesser so soaps. Lots of tractor seat time, and fair sized garden to reduce purchases from grocery stores. Seasonally I'd chase after Spring Bear, Spring Turkey, and enjoy the pursuits of Elk and Deer each fall. Strive towards mastering wild game cuisines based on traditional world cuisines with my own little adjustments. Enjoy the seasonal burning of brush piles each Spring. Ferment juice wines from harvested fruits each fall, mostly apple. Grow my own select hops to create my own IPA variety. And of course use the honey to master baklava!

Income source: goat meat, honey, Ghee, soaps, and other smaller produce products; if acreage permits hay surplus

Don't forget the koi pond for your sushi.

 

[OldPsychDoc]

Let's imagine the day has come, where we are in the same position as EM and the job market is plummeting. The storm clouds are no longer on the horizon by the torrential rain is here.

The ranks of midlevels have surged. The number or residencies have surged and every for profit HCA and similar for profit psych/addiction hospital now has a residency. Newly minted psychiatrists are starting to be jobless post residency. Psychiatrists are clamoring to get non-profit hospital jobs doing C/L and ED coverage for nights/weekends with no increase of pay for night work. The outpatient market is saturated and all commercial insurance now pay well below medicare rates. The VA is saturated and no interest in further expansions. Prison jobs only have openings after the previous person takes the fall for their legal issues. Big Box shops further worsen the issue by mandating the 15min med check again.

Private practice is saturated by those who already have established practices and built up their reputations or by the upstarts who know best how to say, 'Yes!' to those stimulants and benzos. Psychiatrists are applying for Psychologist only postings to do therapy and even get these positions at times.

What do you do? Where do you go? What's your plan B once the blight of the Emergency Physician comes to our peaceful grove?

Tend bar and drive Uber.

 

[dl2dp2]

I think the kind of new jobs that will come into the field you aren't even able to imagine yet, so this doom and gloom is premature.

In particular, I do think as I said in a different thread that the competitive edge in the higher-ranked programs will become more apparent. The "bread and butter" job will change dramatically with the emergence of a telemedicine dominant public sector.

However, the diversity of private-sector jobs will increase, IMO. For example, I imagine that there'll be a much broader type of job where you serve as medical director for a decentralized network of NPs and even PMDs for a portfolio of covered lives, and essentially contract directly with payers as a quality monitor.

I remember some quote from Dr. Strange about "your fear of failure is a reflection of your lack of imagination". I think this is applicable here.

 

[dl2dp2]

My Plan B is to practice non-evidence based, cash psychiatry. The wackier, the better. Think astrologically based, chakra, spirit animal cleanses that correspond to phrenology types. I will earn triple the average psychiatrist income, for half the work.

Actually, that seems like a good Plan A.

No. This is dumb. Do you know what's the most expensive and most fancy thing in the world by far?

Science.

Woowoo is declasse and most rich people don't want any of it.

One huge elevation of prestige of the field in the last 30 years is the leadership (APA/NIH, etc) decided that mental health needs to be science-driven. The vocabulary gets vastly fancier now vs. 1990s. Most of the science right now is not that much different from woowoo, but the pitch is vastly, vastly better.

 

[the5thelement]

I was told once by a colleague that psychiatry will be the last specialty to fall before the AI as it is the most human of them and difficult to automate . I want to think it will be a brighter future for humanity regardless due to innovations in nano technology leading to material abundance (eg. the digital information revolution has brought an overflow of knowledge to more people than ever before)

 

[hebel]

I'd look at politics or the ministry.

 

[rikudo]

Enjoy life as an expert witness for malpractice case prosecuting attorneys.

Defense will insist on NP witness to avoid physician bias and because you are an expert in Psychiatry, not psychiatric nursing

 

[Psychresy]

Defense will insist on NP witness to avoid physician bias and because you are an expert in Psychiatry, not psychiatric nursing

In this world it's likely even the nps have been squeezed out in favor of psychiatric certified nurse assistants.

 

[robellis]

No. This is dumb. Do you know what's the most expensive and most fancy thing in the world by far?

Science.

Woowoo is declasse and most rich people don't want any of it.

One huge elevation of prestige of the field in the last 30 years is the leadership (APA/NIH, etc) decided that mental health needs to be science-driven. The vocabulary gets vastly fancier now vs. 1990s. Most of the science right now is not that much different from woowoo, but the pitch is vastly, vastly better.

Daniel amen

 

[dl2dp2]

Daniel amen

Please. He's a loser. Even I charge a higher fee than he does. No respectable rich person would see some quack like that.

 

[watto]

Defense will insist on NP witness to avoid physician bias and because you are an expert in Psychiatry, not psychiatric nursing

But, your honor! I HAVE prescribed Geodon, Abilify, Lamictal, Xanax, and Haldol. Just not all at the same time!

 

[tr]

Please. He's a loser. Even I charge a higher fee than he does. No respectable rich person would see some quack like that.

But people have no idea he's a quack. It's actually not that easy to recognize if you aren't neuroscientifically trained. You have to know what a PET scan is and what it does and doesn't measure. Some of the things he prescribes are harmless/neutral, others (Sam-E, Deplin) have reasonable evidence for efficacy, although it isn't clear that he prescribes them in the correspondingly appropriate clinical scenarios vs just dropping a laundry list of supplements. Nothing he's doing is overtly harmful.

Most educated but non-neuroscience/psychiatry trained people are going to have a tough time figuring out that he is a quack. It's not like he's peddling colloidal silver.

 

[Attending1985]

But people have no idea he's a quack. It's actually not that easy to recognize if you aren't neuroscientifically trained. You have to know what a PET scan is and what it does and doesn't measure. Some of the things he prescribes are harmless/neutral, others (Sam-E, Deplin) have reasonable evidence for efficacy, although it isn't clear that he prescribes them in the correspondingly appropriate clinical scenarios vs just dropping a laundry list of supplements. Nothing he's doing is overtly harmful.

Most educated but non-neuroscience/psychiatry trained people are going to have a tough time figuring out that he is a quack. It's not like he's peddling colloidal silver.

High dose folate actually has some evidence for increased cancer risk.

 

[Stagg737]

No. This is dumb. Do you know what's the most expensive and most fancy thing in the world by far?

Science.

I'm not sure this is true in a world where Gwenyth Paltrow's GOOP website is considered a legitimate health cite by large swaths of the publi. Especially with her $75 genital-scented candle selling out in hours...

 

[calvnandhobbs68]

But people have no idea he's a quack. It's actually not that easy to recognize if you aren't neuroscientifically trained. You have to know what a PET scan is and what it does and doesn't measure. Some of the things he prescribes are harmless/neutral, others (Sam-E, Deplin) have reasonable evidence for efficacy, although it isn't clear that he prescribes them in the correspondingly appropriate clinical scenarios vs just dropping a laundry list of supplements. Nothing he's doing is overtly harmful.

Most educated but non-neuroscience/psychiatry trained people are going to have a tough time figuring out that he is a quack. It's not like he's peddling colloidal silver.

Absolutely. I mean there's a pretty significant portion of people that will go spend thousands of dollars on things that can be overtly harmful (ex. chelation therapy). As long as you have a good fancy sales pitch and some credentials behind your name (even without), it can be pretty easy to convince people to undergo all sorts of therapies/procedures/imaging/etc. People really like the idea of "doing" something procedural or "visualizing" a problem specifically, and really who can blame them? It brings a level of perceived certainty to very uncertain/nebulous conditions.

In my own practice, I have to often catch myself and remind myself not to just sit on top of my educated high horse and stare down my nose disdainfully at these ideas when patients bring them up. Empathizing with patients about the difficulty of the problems they're dealing with and validating the desire to have some certainty while also gently noting my concern that from my perspective they'll be spending a lot of money on something that I'm not sure has any significant value in terms of planning or treatment is approach I usually end up taking.