Mid Career....left inpatient job...now what?

[SpinDktr]

Hello everyone,

So I am about what I'd consider mid-career as a psychiatrist. Graduated in 2011, did a Geropsych fellowship for a year, and practiced full time from 2012 to 2018 doing outpatient work for a big box shop. It wasn't bad; wasn't really good though either. RVU Basis, and there was an incentive for more production, but if you didn't want to do that, they were okay with not pushing you too hard. I enjoyed the therapists at the clinic location I was at, but when they started having me supervise NP's without additional compensation in 2017 (And the NP's frequently called in, needed refills when they were gone, and they were doing a lot of child work, something really out of my scope...and all the stimulants) it got to be too much.

In 2018 I took a position as the medical director for a Geropsych unit. It was both the best job I've had and the worst. When it was supported by 2 social workers and a recreational therapist and a multipurpose insurance reviewer/intake coordinator, I really enjoyed it, despite the emotional tolls doing this work has. Between 2018 and 2023, the administrative personnel made many decisions to pare it down to a really bare bones unit. In particular the last 2 years have been rough. 2 of those supportive positions were eliminated, and their demands on me to increase unsafe admissions/see more dementia patients and place nurses at risk were huge red flags. I still really enjoyed many of the nursing staff and so it was a difficult decision in many ways, but I put in my notice. They feel like they will be able to run the unit with telepsych....well good luck to them.

I am very comfortable with complex pharmacology, clozapine prescribing, and treating the elderly in a safe way, so feel like I should be able to find the job I want.

Today is my first official day of being "unemployed". I feel comfortable with the decision, but so far all my plans to find a replacement job haven't worked out. I interviewed for 2 other inpatient positions, and received very positive feedback...but ultimately didn't get the jobs. These positions would have been better supported that the job I just left (one for the state, the other a private company but run by physicians). I live in the midwest....low COL area, but fairly big mortgage and 2 kids that will be going to college in the 3-8 year time frame. So I'm not in a position to be out of work for too long. We have savings and I don't absolutely need income for a little while. Student loans and cars are at least paid off.

I'm really strongly considering private practice, but the town we live in is very small, and couldn't support me. The bigger metro areas around here are fairly saturated, but there might be some midsize towns in the "somewhat local" area I could look at. There are opportunities out there, but I feel so lost in doing basic things like finding an office, considering how long rent will be needed, getting malpractice, etc. I'll be combing through some of the posts here in the next few days though to learn.

I feel like a lot of people on this forum enjoy private practice and I am definitely leaning that way at this point. I have some interviews coming up this week....but I'd appreciate any words of wisdom from people who have been in private practice and recommendations as to where to go from here!

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[whopper]

There's a learning curve to private practice where residency doesn't prepare. If you did inpatient you know psychiatry but you will have to know some minor accounting, local laws in regards to employment, getting several things yourself that an organization would've done for you such as pick an EHR, etc.

 

[Sushirolls]

Private Practice in Progress

Hey everyone, probably the last real update from me. Probably shutting down the practice at the end of Oct as we're planning to move out of the country. Things have grown at about the rate expected but we've been declining most new patients for a bit in anticipation of the move. Probably would...

forums.studentdoctor.net

That thread will give you a glimpse.
There are a few others on here who are doing PP, too. But buried in that thread are 2 possible checklists to give you more "how to" guidance to spring forward from.

 

[Sushirolls]

If you like Geri... you could skip the whole EMR cost.
Just do paper charts, scan them with a fast Fujitsu to a hard drive that you can encrpy.
Make your notes pure chicken scratch hand written, or templated, you'd be fast on notes.
Geri side, a lot won't or can't do online EMR stuff, so just skip it.
Or use Luminello to scan in your notes? and lean into its other features for billing, scheudling, etc.

 

[comp1]

How the heck did you not get the inpatient jobs? What kind of places are these where they can be selective and not straight up begging? Private practice seems like a massive change to me personally and really stressful, but I've never even been vaguely interested in it...

 

[PikminOC]

How the heck did you not get the inpatient jobs? What kind of places are these where they can be selective and not straight up begging? Private practice seems like a massive change to me personally and really stressful, but I've never even been vaguely interested in it...

They hire midlevels for inpatient now. They are much cheaper

 

[SpinDktr]

There's a learning curve to private practice where residency doesn't prepare.

Definitely. I have an interview with a small counseling practice tomorrow that seems willing to talk to me about working there. They've got 3 counselors and no provider, but they have an established location and the space for me. I will update tomorrow; actually going totally solo seems a bit overwhelming.

If you like Geri... you could skip the whole EMR cost.

I've thought about doing nursing home visits and establishing a small/mobile geri consulting business too. I know of another doctor in the area that does this and he has no EMR. He said he has the capacity for 8-12 hours per week with him but the ability to grow. This seems like the best choice for me right now...but part of me wants my own clinic too, but this doesn't seem so bad.

How the heck did you not get the inpatient jobs? What kind of places are these where they can be selective and not straight up begging?

It wasn't an NP...actually for the state I think it was an internal applicant who had more system experience that beat me. For the other...I don't really know yet. They haven't said, but I feel the person who was supposed to be leaving decided to stay. Maybe I'll eventually find out...but it has been a strange experience for sure.

 

[Merovinge]

I think it sounds like you are a well trained and seasoned psychiatrist that many places would want to bring into the fold who hit a small N bad luck sample with 2 job hunts. I think your geographic area likely accounts for less than typical number of job options which might make this feel a bigger deal than it is. If you spoke to people in non-medical fields about not making it past 2 job applications that would be a blip on the map/expected part of the process.

Nursing home or gero oriented 1099 work makes a lot of sense, I would see if any NH need help of if there are any local gero focused PHP/IOPs that need psychiatric services. Best of luck to you, I do bet that a year from now this time just feels like a nothingburger.

 

[Candidate2017]

Definitely. I have an interview with a small counseling practice tomorrow that seems willing to talk to me about working there. They've got 3 counselors and no provider, but they have an established location and the space for me. I will update tomorrow; actually going totally solo seems a bit overwhelming.

As a physician I would loathe working for counselors as the sole "prescriber/provider". It's basically letting the dumbest, weakest kid on the playground take my lunch while they tell me to prescribe for their anxiety and attention "clients". The level of professionalism is magnitudes lower, or totally absent, working for people who have no idea how medicine works, unlike working for a physician practice or even hospital CEO.

I've thought about doing nursing home visits and establishing a small/mobile geri consulting business too. I know of another doctor in the area that does this and he has no EMR. He said he has the capacity for 8-12 hours per week with him but the ability to grow. This seems like the best choice for me right now...but part of me wants my own clinic too, but this doesn't seem so bad.

Why not both?

It wasn't an NP...actually for the state I think it was an internal applicant who had more system experience that beat me. For the other...I don't really know yet. They haven't said, but I feel the person who was supposed to be leaving decided to stay. Maybe I'll eventually find out...but it has been a strange experience for sure.

Maybe it was their current doctor who played the game of "I'm quitting unless you do x, y, and z" as part of their negotiation.

 

[Stagg737]

How the heck did you not get the inpatient jobs? What kind of places are these where they can be selective and not straight up begging? Private practice seems like a massive change to me personally and really stressful, but I've never even been vaguely interested in it...

Let's not forget there's somewhere around 1,500 residents/fellows graduating every year who will enter the workforce in addition to anyone else who is changing jobs. There's still competition out there, it's not like we can just get any job we want just because we apply. I had 2 positions I applied to get filled by people who had applied first. I still had (and have if I choose) plenty of choices, but it's not like there's no competition. Plus there's plenty of places that would rather just eat the cost and not hire someone than hire a psychiatrist who knows their worth and they can't take advantage of.

I've thought about doing nursing home visits and establishing a small/mobile geri consulting business too. I know of another doctor in the area that does this and he has no EMR. He said he has the capacity for 8-12 hours per week with him but the ability to grow. This seems like the best choice for me right now...but part of me wants my own clinic too, but this doesn't seem so bad.

One of my attendings in med school did this. He contracted with 4 or 5 NHs where he would see their residents 1 day a month and get paid somewhere between $3k-5k per month per NH. He basically just made sure people were grossly stable and didn't need to go inpatient. I guessed he was pulling in an extra $180-200k per year doing that.

 

[calvnandhobbs68]

As a physician I would loathe working for counselors as the sole "prescriber/provider". It's basically letting the dumbest, weakest kid on the playground take my lunch while they tell me to prescribe for their anxiety and attention "clients". The level of professionalism is magnitudes lower, or totally absent, working for people who have no idea how medicine works, unlike working for a physician practice or even hospital CEO.

Depends on what the setup is, I'm 1099 with a large therapy group and nobody tells me anything about "how to prescribe". I sometimes get goofy referrals or inappropriate stuff therapists say to the patients about meds but I get that from outside therapists too, nobody is telling me how to do my job.

I would actually worry that's too small of a group to be useful to you OP, 3 therapists is not that many and probably doesn't have a ton of name recognition or referral stream in the community which is what you're looking for to be worth whatever cut they'd be taking.

 

[dl2dp2]

The main barrier to PP is marketing. Basically, you need people who are looking for a psychiatrist to be able to find you within the state that you are licensed and then seek your service. There's no straightforward formula, but in the age of telemedicine, I don't think that your office location per se matters greatly. This is also a trial-and-error process.

Once you figure that out, things flow very nicely. MUCH MUCH more so than at a facility. In particular, facilities themselves need to solve that problem, and often aren't very good at it.

 

[finalpsychyear]

Get a main gig and try and carve out 1 full day or half day to work/build that. Less ideal is a 5 day main gig and doing this on precious Saturdays.

Yes the midlevel threat is real and you are seeing some of it. Few years ago there was non stop inpatient requests on my phone/emails now not much.

My caution to everyone is have a main gig that you can climb up the ladder into admin roles while having a side PP that you grow over the years. Eventually the PP if you want could be your main gig years later or you keep your toes in both and your job will know that and maybe push you around less. If you truly are in a isolated area you may need to move to ideally capture this type of set up.

 

[R. Matey]

Definitely. I have an interview with a small counseling practice tomorrow that seems willing to talk to me about working there. They've got 3 counselors and no provider, but they have an established location and the space for me. I will update tomorrow; actually going totally solo seems a bit overwhelming.

A bit of a thread hijack, but how common is it for you folks to work in a non-MD owned PP? Is it fairly messy legally, straight-forward, or depends?

 

[clausewitz2]

A bit of a thread hijack, but how common is it for you folks to work in a non-MD owned PP? Is it fairly messy legally, straight-forward, or depends?

If the owner of the practice actually understands what a contractor is, then it is pretty straightforward. I do this most days of the week and basically I pay a fixed percentage of my collections for advertising and admin support effectively.

 

[R. Matey]

If the owner of the practice actually understands what a contractor is, then it is pretty straightforward. I do this most days of the week and basically I pay a fixed percentage of my collections for advertising and admin support effectively.

Appreciated. Someone told me that MDs had to be a co-owner/partner in a practice in order to practice there if the business was owned by psychologist, which didn't sound right to me.

 

[clausewitz2]

Appreciated. Someone told me that MDs had to be a co-owner/partner in a practice in order to practice there if the business was owned by psychologist, which didn't sound right to me.

Unless it is some bizarre state thing, not so much.

 

[SpinDktr]

Maybe it was their current doctor who played the game of "I'm quitting unless you do x, y, and z" as part of their negotiation.

I've thought of that, and think that it is a good possibility. It would be nice to know, and at some point I'll probably find out. The psych community is pretty small around here.

I would actually worry that's too small of a group to be useful to you OP, 3 therapists is not that many and probably doesn't have a ton of name recognition or referral stream in the community which is what you're looking for to be worth whatever cut they'd be taking.

Definitely; I wouldn't be there more than a day or two a week. It would be part time while keeping my feet wet building up a NH visits, and because the guy I know doesn't have more time than that.

 

[PikminOC]

Op if you thought the nurses write too many stims, wait until therapist referrals. They are adamant 90 percent of their patients have ADHD or some neurodiversity and will expect you to prescribe.

 

[psychmd03]

One of my attendings in med school did this. He contracted with 4 or 5 NHs where he would see their residents 1 day a month and get paid somewhere between $3k-5k per month per NH. He basically just made sure people were grossly stable and didn't need to go inpatient. I guessed he was pulling in an extra $180-200k per year doing that.

This is a solid way to leverage that Geri fellowship. I have a few people I know that do very well with this style set up.

 

[dl2dp2]

A bit of a thread hijack, but how common is it for you folks to work in a non-MD owned PP? Is it fairly messy legally, straight-forward, or depends?

MD ownership isn't the panacea. If the MD owner doesn't open the books and you have no partnership track potential (I personally know of a practice like this), in general your time/effort will be an instrument of exploitation by design.

Generally, owners keep key numbers very close (negotiated rates with insurance, total revenue, profit margin, etc.)

 

[AcronymAllergy]

Appreciated. Someone told me that MDs had to be a co-owner/partner in a practice in order to practice there if the business was owned by psychologist, which didn't sound right to me.

I believe it depends on the state. Some states allow medical practices to have non-physician owners and some don't. States can also have different definitions of what a healthcare/medical clinic is. At least as far as I know.

 

[whopper]

I've seen a lot of MDs not know WTF is going on with stuff outside of medicine. (And a lot of MDs that don't know WTF is going on with medicine).

Private practice is a learning curve that can be overwhelming. I don't know if I would've entered it had I not entered a practice where they did all the stuff for me. When the people "doing the stuff" such as accounting and billing eased back due to getting older it forced me to learn these things myself and this was uncomfortable to say the least.

 

[Sushirolls]

Op if you thought the nurses write too many stims, wait until therapist referrals. They are adamant 90 percent of their patients have ADHD or some neurodiversity and will expect you to prescribe.

So true. So dang true.
As much as I want to complain about this... I'd still rather have this than a heavy cannabis population. And I like addiction.

 

[Stagg737]

Yes the midlevel threat is real and you are seeing some of it. Few years ago there was non stop inpatient requests on my phone/emails now not much.

Idk if this is due to mid-levels in your area or just recruiters not sending you stuff because you didn't respond or weren't looking. I still get multiple e-mails a week about available inpatient positions from recruiters and I could probably find an inpatient position fairly easily if I wanted to. If I were willing to move and be flexible geographically, I know I could easily.

 

[finalpsychyear]

I've seen a lot of MDs not know WTF is going on with stuff outside of medicine. (And a lot of MDs that don't know WTF is going on with medicine).

Private practice is a learning curve that can be overwhelming. I don't know if I would've entered it had I not entered a practice where they did all the stuff for me. When the people "doing the stuff" such as accounting and billing eased back due to getting older it forced me to learn these things myself and this was uncomfortable to say the least.

Also MD's not knowing WTF in or out of medicine. I spent my entire 4th year of residency shadowing PP attendings and a recent grad who started his own PP to pick up pearls and keys and worked last 6 mo of my chill 4th year on setting up credentialing and all insurance etc.

 

[finalpsychyear]

Idk if this is due to mid-levels in your area or just recruiters not sending you stuff because you didn't respond or weren't looking. I still get multiple e-mails a week about available inpatient positions from recruiters and I could probably find an inpatient position fairly easily if I wanted to. If I were willing to move and be flexible geographically, I know I could easily.

I use it as fuel for the fire to keep me churning at my current pace for a few more years but of course its going to have an impact. I have no desire to do inpatient but for others i would be milking it while the well is full.

 

[whopper]

PP: You'll need a biller. Some billers suck. You won't know if you got a good one till you can kick the tires around for some time. By the time you figure out they're good or not, other than that you'll likely not have a good barometer to know what is good and what is not good, you're going to graduate to the sophomore stage where you only think you know.

Accounting-you will have to have a minor skill in this. Quickbooks makes this much easier and makes this aspect much less scary.

Lawyers: Just in case. You will be in situations where once in awhile you will need to consult with one. Not often, but it will likely happen. I've had to use a lawyer on average about once every 2-3 years. None of them were malpractice cases, but stuff like getting a restraining order against overzealous patients, knowing the tax laws, etc.

Hiring and firing. You need to know the local laws regarding hiring and firing. You just simply fire a person and don't know what you're doing you may end up sued for discrimination or end up paying this fired employee's unemployment benefits out of your pockets for months.

Software: You will need an EHR or some other filing system for account for records.

Many doctors I know can't do anything outside of practice medicine.

 

[SpinDktr]

I met with the owner and her biller/scheduler today, and they seemed pretty competent. The owner actually seems straightforward and really enjoys groups and kids. She likes what she does and seems good at it, and not expecting too much from a prescriber other than feeling like my schedule would be packed day 1 (and not anticipating some of the roadblocks I can already see). The biller/scheduler seems quite competent too. She feels like she can get me credentialed with local insurance companies and even listed off the time it usually takes for the more responsive ones, and less responsive ones. Not an overnight process, but It sounded like she knew her med management codes although hasn't billed them recently.

They said they would be willing to consider either 1099 or W2. They have therapists who do both with their clinic now. They also are open to me working 1 or 2 days per week there. They thought I could work more than that, but I don't think there would be a reason to do so to begin with. They are moving to a larger clinic in December, and their goal is to grow, and would like a psychiatrist to be part of it.

I have no current LLC, name or presence; is this something I should do? I know it isn't too much to apply for an LLC in this state. I also have not applied for individual malpractice yet, but I've been looking at it the last few days. I'm leaning toward PRMS/20 hours/wk at this point.

 

[calvnandhobbs68]

I met with the owner and her biller/scheduler today, and they seemed pretty competent. The owner actually seems straightforward and really enjoys groups and kids. She likes what she does and seems good at it, and not expecting too much from a prescriber other than feeling like my schedule would be packed day 1 (and not anticipating some of the roadblocks I can already see). The biller/scheduler seems quite competent too. She feels like she can get me credentialed with local insurance companies and even listed off the time it usually takes for the more responsive ones, and less responsive ones. Not an overnight process, but It sounded like she knew her med management codes although hasn't billed them recently.

They said they would be willing to consider either 1099 or W2. They have therapists who do both with their clinic now. They also are open to me working 1 or 2 days per week there. They thought I could work more than that, but I don't think there would be a reason to do so to begin with. They are moving to a larger clinic in December, and their goal is to grow, and would like a psychiatrist to be part of it.

I have no current LLC, name or presence; is this something I should do? I know it isn't too much to apply for an LLC in this state. I also have not applied for individual malpractice yet, but I've been looking at it the last few days. I'm leaning toward PRMS/20 hours/wk at this point.

Ah having an in-house biller is great, one thing I'd realize though is that the coding you're using is going to be quite a bit different than the therapy codes they likely use and making sure the biller is familiar with E+M codes, psychotherapy add-ons.

You don't have to have an LLC. Single employee LLC and sole proprietorships are essentially treated the same way tax-wise federally. There may be state tax laws that are more advantageous to you as an LLC vs sole prop, you'd have to check that. There's no difference in liability if you don't own your own building or anything since the LLC doesn't protect against malpractice suits in any way, which is your main liability (not if someone slips and falls on your building floor for instance). You can also file with the IRS to get an EIN as a sole prop so you can keep your SSN from being all over documentation for the group, they just pay you using your EIN which is basically interchangable when you go to file taxes.

If you were planning on owning a building, leasing an office, having employees, owning equipment, etc (so basically if you were setting up your own physical private practice), you'd want to be an LLC or an S-Corp since the business entities then start really separating out business assets vs your own assets to protect you more. You also can't hire people for your business as a sole proprietor (thus the sole part of it).

 

[SpinDktr]

As an update...

The inpatient position I interviewed with finally got back to me. I interviewed there 6 weeks ago and was thinking they were ghosting me. They hadn't even responded to the emails I sent; I think there was definitely some other negotiating going on there with the person who is leaving. Don't know the details on that yet. But they gave me the basics of the position today; FT employed and pretty happy with the salary at $390k/yr. It would be busy, but not more than what I have been used to. Also more support from having other doctors around. I really miss that.

But I also interviewed yesterday for what I would consider a "little box" outpatient position. It's a smaller/local group of doctors, and I liked everyone I met with. They seem like they would be flexible and consider a 0.6 FTE position which would allow me to do nursing home visits. It seems more relaxed and less stressful. No salary given at this point; they would like someone to be full time, but as we all know it's hard to get good psychiatrists. They also have ECT and TMS which around these parts is very difficult to get, and pretty impressive from a smaller group.

Leaning towards the second option at this point...

 

[Merovinge]

As an update...

The inpatient position I interviewed with finally got back to me. I interviewed there 6 weeks ago and was thinking they were ghosting me. They hadn't even responded to the emails I sent; I think there was definitely some other negotiating going on there with the person who is leaving. Don't know the details on that yet. But they gave me the basics of the position today; FT employed and pretty happy with the salary at $390k/yr. It would be busy, but not more than what I have been used to. Also more support from having other doctors around. I really miss that.

But I also interviewed yesterday for what I would consider a "little box" outpatient position. It's a smaller/local group of doctors, and I liked everyone I met with. They seem like they would be flexible and consider a 0.6 FTE position which would allow me to do nursing home visits. It seems more relaxed and less stressful. No salary given at this point; they would like someone to be full time, but as we all know it's hard to get good psychiatrists. They also have ECT and TMS which around these parts is very difficult to get, and pretty impressive from a smaller group.

Leaning towards the second option at this point...

Sounds like you are already in good shape!

 

[comp1]

$390k salary sounds very suspicious...even if this was in Silicon Valley, that's pretty darn high. That would be more like what someone would pull in before taxes and expenses and benefits in a 1099...