Job search feedback sought - Psychiatry

[Stein]

Happy Thursday everyone,

I've been learning a tremendous amount from these forums and from the blog, thank you all for sharing your accumulated wisdom with those of us just getting started. I've been seeking out input from colleagues, mentors, and from online resources to try to evaluate and compare options for post-residency employment next year. I'm in my final year of psychiatry residency, and plan to start outpatient employed work next year in a popular mid-sized city in the Midwest. I'm currently comparing three outpatient employed positions at different groups in the same city - one academic and two private groups. Any input/thoughts/ideas are appreciated, I'm brand new to this. Benefits and time off are all similar, other than weekend/holiday obligations as below.

Option #1: Small private health system, primary care-based, offered FT outpatient position with ~36 patient care hrs/wk, no call, no weekend rounding, no holiday coverage obligations. No hospital component. Compensation straight salary only, no bonuses, starts at about $215k and ramps up yearly on a schedule to ~235k in 2 years but with no bonuses or productivity component. No non-compete, moonlighting/telepsych is definitely possible.

#2: Large private health system, primary care-based but also associated with large hospital nearby, offered FT outpatient position with ~35-40 pt care hours/wk, q6 weekend rounding (fairly busy), 1-2 weekday night phone call/month (from home only, expect to get called regularly for ED/inpt orders, admits.) No extra compensation from the inpatient/phone coverage, that is included in base. Compensation is base+clinic RVU, per current psychiatrists there, this ranges from $240k starting, ramping up to $250-350k depending on hours/RVUs, average $250-260k including call, bonuses, etc. Unsure about non-compete, but I think moonlighting/telepsych would be possible, will clarify.

#3: academic system, FT outpatient position with about 40 hours total including clinic, supervision, teaching, no protected time to start. Occasional call (1 weekend per month or so?), will have to cover a few holidays/year inpt/consults. Compensation base + RVU, per current faculty can range from $240-260k+ depending on hours/RVUs worked. Non-compete included, no moonlighting or telepsych but could add hours/RVUs for productivity bonus.

I have not looked into private practices in the area, is this something I should consider starting out? My thought was to start with a structured organization that can fill my schedule, provide benefits, and a steady paycheck as I pay loans/mortgage, etc, until I'm more comfortable with practicing. My other thought/question was to pair one of these positions with a telepsych role or moonlighting - possible with #1 and #2 above, but not with academic #3.

[LizOB]

I think the first question you need to ask yourself is whether you want to be in academics. Do you want to teach/supervise residents and students? If not, don't do academics!

Comparing the first two options, #1 sounds great if your priority is to only work M-F during the day. Not a ton of jobs in medicine that can offer that. However a downside in salary (aside from imposed ceiling on compensation) is that people tend to try to get out of work when they're not getting anything out of it. You're on vacation and one of your patients needs to be seen urgently by a colleague? And they're booked already? Fat chance with a salary but with productivity people are more inclined to works patients in like that, which I honestly think is a win-win.

#2 sounds like a ton of work- those regular overnight phone calls will wear on you, but it also sounds like the best potential for the highest salary. What are your priorities? Are you single and/or have a ton of debt and want to make as much as possible? Or do you have a family and want to attend the kids' soccer games Saturdays? We can't answer that for you

[Dr. Mom]

I'll be curious to see what wideopenspaces, FIRESHRINK, and Lithium have to say.  PM them if they don't come along.  I would stay away from a position with a noncompete if you want to stay in this area.   I will plug keeping the option of telepsych open.  I do telemedicine in Peds and have enjoyed it very much.  Good luck!

[Lithium]

I've worked in a large private organization for a few years.  Here are my thoughts:

- Agree above that given the similarity of these positions, the most important distinction is academic vs non academic.  I wouldn't be on the fence about this.

- after that, if these are pretty similar jobs, next most important factors are quality of your colleagues and administration.  Which organization and management group do you trust most to work with?  An organized group of docs that supports each other and acts in their collective best interest is an enormous benefit.

- as far as compensation and workload goes, I don't like that any of these jobs are mostly salaried.  It leaves you vulnerable to mission creep.  Keep in mind that every job has a lot they will expect and demand you to do, but the only thing they want to pay you for is seeing patients.  I think the larger and more rigid the organization, the more bean counters there are to give doctors uncompensated busywork.

- the noncompete is a big deal, but I wouldn't overvalue how much time you'll have to work on the side for moonlighting and telepsych.  These jobs look attractive now, but they probably aren't selling you in an unbiased fashion on how draining they might be Day to day.  You don't want to underestimate the effect working too much now can have on burnout levels years later.  Toast can't ever be bread again!

if it were me, I would definitely look into private practice or locum Tenens.  I wish I'd done locus tenens for a few years while I learned the business and politics of medicine better.  Full time employment is the default secure path for new grads, and for good reason, but you give up precious flexibility and independent bargaining power in the process.

i know that isn't very psychiatry specific, but I'm an inpt doc and don't think the clinical caseload is that different or important for making your decision.

[childay]

Like lithium, inpatient psych here.

You are getting good advice re: academia.  A few thoughts.

How hard do you want to work?  Are you satisfied the workloads will be similar in these positions?

You mention base+RVU in the latter two positions.  However you don't list the base or the RVU details. I am non-academic but it sounds like the sort of position where you have a full time clinic and then they expect you to teach and supervise.  This is based on the listed salaries, which seem high (again I am not in adacemia so cannot say for sure).  In looking at the second two positions I would request very specific numbers on the other "providers" patient contacts, hours worked, wRVUs per year etc.  Just having the salary range isn't particularly helpful in comparing..

The second position is not paying you RVUs for the inpatient work, just clinic?

Obvioulsy the noncompete etc are important as with any contract.

PM if needed.

[Stein]

Thanks so much for all the input and feedback, I really appreciate you all taking the time to help.

Re: LizOB - Great point about academics. The idea of teaching, supervising, writing, sitting on committees, etc, sounds rewarding and interesting to me, until I start to think about the day to day reality of managing a clinic, a panel of patients, and then adding academic evals, take-home committee work, putting together an academic portfolio, writing - most of which is going to be uncompensated effort. The numbers for the academic position above are not the base salary, the 240-260k range is the final take-home gross that a few early career faculty from this university mentioned to me, which includes their RVU incentive. I hesitate to move any further along this path as I've seen firsthand what unpaid "mission creep" looks like, and academics does it best. Every day in my academic program I see early-mid career faculty who are working their tails off, and it's tough to make that sacrifice not only for me but for my young family as well. And no moonlighting or telepsych with this academic position (though there'd be no significant time left over anyway).

#1 appeals to me given I have a young and growing family, though it does sting to see the salary cap out at that level, even if I see a full load of patients. It might be worth it just to know I have every weekend and holiday off, with the ability to tack on telepsych or moonlighting hours to get going on investments, mortgage, college funds. After looking briefly online, I'm seeing telepsych running $150-170ish/hour, does that ring true for the psychiatrists here? Would I be better off moonlighting those hours in an ER/inpatient unit? It would be nice to be able to boost income on an as-needed basis, then let those side gigs go as finances fall into place.

#2 certainly has the most income potential, but concerns me re: burnout. From what I've heard, the weekends and home call are no joke, and I'd be covering my share of holidays. To answer your question, we were able to pay off our student loans in the past few years thanks to fairly strict budgeting and mostly due to my wife working hard during the years I was losing us money in med school. So no urgent need to pay off debt, but still need to get going on saving for mortgage downpayment, investments, etc. Cost of living in this area is moderate, on the higher end for the Midwest but reasonable.

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Re: Dr. Mom - Thank you! Yes, non-competes scare me, as we really want to stay in this particular area for a bunch of reasons. Telepsych is a neat option, I feel like I could add on a few hours/week and boost income while not feeling tied to an office, commuting, etc.

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Re: Lithium - Thanks so much for the input, this is very helpful. I've appreciated your posts across the forum. Sometimes the best advice is hard to hear, and it's painful to admit that academics is probably not for me at this point in my life, which runs counter to the culture and system I lived and breathed for the past 7 years. Most of my mentors and role models are in academics, so it's a tough decision.

Good point with mission creep, which concerns me with big academic systems and big regional/national health systems. I've spent enough time at the VA to know exactly what you are referring to. I haven't found any positions with pure productivity compensation yet, but I'm sure there are some in that area. I'm not sure if my hesitation to join a small private single-specialty group is well-founded or unnecessary anxiety, it's just new to me.

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Re: childay - I don't think the workloads are similar between the 3. It appears that the large private group, #2, works docs hard. High volume, lots of call, high compensation to recruit. It's very much a corporate feel. The academic position looks like a typical academic job to me - reasonable clinical load with lots of extra unpaid work on the side. I don't have all the information yet on base, RVU structure - the 240-260k for academic role is total compensation, per a few early career psychiatrists there, and includes base+RVU. i'll definitely get more details.

Correct, RVU bonus from academic position and #2 are clinic only, inpatient work is considered covered in base salary at both. Bummer.

 

Thanks again, lots to think about. Would also love to hear any experiences with telemedicine, in terms of setting up, negotiating, and how many hours people find manageable in their spare time. I'm thinking maybe a few hours weekday night(s) or maybe a few hours on a weekend morning.

 

 

[childay]

Another thought,

If I were looking into outpatient jobs, I would be very concerned about workload and details in the clinic, how much control you will have over scheduling, if you are okay seeing 10min med-checks, psychotherapy support, etc.

Stein wrote:

I don’t have all the information yet on base, RVU structure – the 240-260k for academic role is total compensation, per a few early career psychiatrists there, and includes base+RVU. i’ll definitely get more details.

Click to expand...

Although total compensation is obviously important, you will need to understand whether the RVU $ multiplier is fair / similar across these jobs, and any other non-productivity compensation and how that factors in.  I do have recent survey data if needed.

[Stein]

Great point @childay. The academic and large private group (#2) have fairly flexible appointment scheduling, though #2 definitely encourages shorter visits and higher RVUs/hr (per docs there and directly via compensation model). #1 has a fixed appointment scheduling system, 60 minute new patients and 30 minute return visits, which I find appealing. No pressure to see more pts/hour and no extra $ to see more pts/hour - it's part of a health maintenance insurance system so is invested in quality care and reducing costs, rather than RVU generation. I'm not seeing much support for seeing my own psychotherapy patients in any of these three, which I'm ok with at this point. There's therapists readily available for patients in all 3 systems.

Would love to see any survey data you're willing to share, feel free to PM me - I won't share further without your permission. Thanks.

 

 

[Lithium]

Sounds like you prefer non-academic, and it sounds like #1 has the better mission.  If it really is 36 hours a week with no call it sounds pretty appealing, and maybe doing moonlighting wouldn't be that hard.  Hopefully the contract is pretty granular about all that.  It is always better I think to have a laid back (or even part time) W2 job with benefits supplemented by optional 1099 work than be trapped in an intense FT position that grinds you as hard as they can.

other possible pitfalls with option 1 (small organization) - who covers your patients calls while you're on vacation, or at 2am?  Is none of your salary contingent on quality metrics (patients using the portal, satisfaction ratings)?  That's pretty rare not to have to worry about.

[Stein]

The current contract for #1 is pretty specific and thankfully fairly simple. I hear you on the smaller organization, #1 is by far the smallest of these 3, with all the accompanying pros and cons. Currently they have a coverage system where the other psychiatrists and midlevels cover for each other on vacation and for conferences. They contract out with other systems for emergent care and inpatient care in town, this system does not own or staff a hospital or ER. They definitely monitor quality metrics, it's a big part of their culture, though there's nothing in the contract or in my discussions with them that involves taking a salary hit from low metrics. That would be worth asking though. Thanks again.

[FIREshrink]

Assuming you do not want academics, #1 sounds much more attractive. Then you can moonlight (at a higher hourly rate to boot) to bump up your salary, on your own terms. The higher salary of #2 Is not enough to compensate for the weekends, the nights, and the busy pace.

I agree that the people you work with are extremely important. Your nursing staff, your patients, and of course your physician colleagues. I lucked into a great group of people in my first job and as a result have never left (14 years and counting). Going to work with people you like and respect makes all the difference in the world.

Those salaries generally sound about right. #1 seems to offer the least room for growth, and truth be told if you are a productive psychiatrist, you will be underpaid at $215k-$235k. But that may not be for a couple years, while you grow into practicing, and then you can renegotiate your contract or take a different job.

Psychotherapy is currently well reimbursed and if you are on a production model you should inquire how that will be supported in your practice. If all you do is med checks you will not be optimizing your production. A 99214 is 2.0 RVU and typically takes 20-30 minutes. But in 30 minutes you can easily do a 99213 and a 90833 and that is 2.9 RVU. It's also very possible to do a 99214 and a 90833 in 30 minutes and that is 3.5 RVU (although it is not possible to do those back to back to back). Ask about the culture and logistics of doing therapy.

[Stein]

Thanks for your input FIREshrink. Re: low starting salary - That's what I suspected, and is probably my only reason for hesitation, though the group was transparent that they start out new grads below market median rate and ramp them up on a schedule over their early years. I'll ask them about the therapy component, as I'll definitely have time with 30 min RVs to do productive and potentially rewarding therapy work with most patients. In your estimation, what salary range would you expect to see 3-5 years in to the job, assuming FT outpatient with 60 min new, 30 min RV? Closer to 240-250k? It's been hard to tease out given different offers have such different call schedules, reimbursement structures, etc. Thanks for your time!

[FIREshrink]

My employer does a couple unusual things to my benefit, which I can explain later, but in short, we use the AGMA median for the western US, which is about $60 per work RVU. Thus if you are a productive and therapy oriented psychiatrist you can routinely bill 5.8 RVU per hour and therefore earn $300+ per work hour. Now of course that does not include non-productive time such as emails, phone calls, no shows, lunches, meetings, etc. But in a typical busy productive full clinic day, I expect to generate 25-30 work RVUs and thus earn about $1500-$1800 per work day. If you work 5 days per week and take 7 weeks off including holidays that comes out to 45x5x(1500-1800) = $330-$400k. Why don't most psychiatrists make that much? They don't do therapy; they don't work five days per week; they aren't full; they aren't machine-like in their production; they aren't paid on production; etc. And personally I could not work at that pace 5 days per week, 45 weeks per year. Some of my days are lighter, intentionally; I often leave mid afternoon on Wednesdays. But if you can and want to work at breakneck pace, you should be paid for your productivity. Job #2 doesn't seem to reward you enough unless salaries in the midwest are substantially lower.

The median production seems to be running around 4100 work RVUs per year right now. I work 200 days per year (4 days per week and 1 weekend per month) and always exceed that number. I'm also paid for administrative work.