October 7, 2006

Psychology vs. Psychiatry

I was sent a question from a recent college grad about whether to go into psychology or psychiatry.  I don't know which is better; you should decide which you like yourself.  But I can help you succeed in either one.


Since I graduated residency, I have never-- never-- had a patient ask me where I went to college, medical school, or residency.   Whether I went to Harvard or Guatemala,  no one would know.


It's true that people assume I'm good because I work in an academic institution, so it lends me credibility. And it helps in court, tremendously, to say I work at said academic institution. 


But if you are thinking of being a private practice clinician, it matters not  a lick where you went to school-- or fellowship  (so don't go.)


What matters is how you set up your practice. 

Following the logic above-- and you will initially doubt this, but bear with me-- it doesn't matter, financially, whether you go into psychiatry or psychology.   What matters is how you go into the practice of either.

I'll just refer to psychology right now.  And I'm going to talk about money only, not personal fulfillment or career advancement or awards-- all that is your business, and there are plenty of resources to help you.  I'm trying to tell you about the money side, which no one else seems ever to want to talk about.

The key difference in the need for psychiatrists and psychologists is the duration of follow-up.  The shortage for psychiatrists exists for long term follow-up in Medicaid/Medicare patients. The shortage for psychologists is for short term and CBT for private insurance patients.

To get rich in psychology, it is not necessary to have the best paying patients, but rather to have a steady stream of patients, whether they pay well or not.  If you have a waiting list, you win.   How to get such a stream?

If I was a good clinical psychologist-- PhD helpful but not necessary, master's is fine-- I would find two or three good psychiatrists and set up a group.  Every patient that comes through them has to have at least an initial eval with you, and vise versa.    This guarantees you volume, which is great, and many of the patients will continue on with you.  But even those that don't are still a win, because that first session can be billed at a higher rate. 

I would find the nearest academic institution with a "residents' clinic."  That's a gold mine.  There are a lot of private insurance patients there, who need short term therapy.   These academic clinics almost never have enough therapists, because the ones that are on staff are not really incentivized to see extra patients; they're on salary.  So there is a massive number of patients who could benefit from therapy, but are on a waiting list, etc, etc.  It seems unbelievable, so I'll say it again: university clinics need to refer out.   If you can get that overflow, if you can get one or two docs there to vouch for you and tell everyone to refer to you, you win.  How do you get them to vouch for you? Well, go back to my Steps: you need a specialty.  Do you do CBT?  Supportive therapy?  Grief counseling?  You can do everything if you want, but it is vital that you be known for regular therapy AND something specific.  You business card should read, "Grief Counseling and General Therapy" or something like that. 

That makes you different and better than other therapists, even if you're not.  And makes it ok for you to approach a psychiatrist to get referrals.  "Hi, I'm a therapist, send me patients" is very different than, "Hi, I specialize in Grief Counseling, short and long term, so if you have any patients..."  Again, the unbelievable truth about referrals: the referrer doesn't actually have to be certain you are an expert-- hell, they don't even have to know you are legitimate.  If your niche is sufficiently small, they simply won't have any other names available when they get cornered by a patient.  And if they have no other such "expert" in their minds, you will get the referrals.  And if just one patient reports back to the psychiatrist that you're good, you win.

Try to meet psychiatrists wherever you can, but the best place I know is through drug reps.  Go to one of the "drug dinners" and meet the psychiatrists who attend.  Find a psychiatrist-parent-- hell, any kind of doctor-- in your kid's school, meet them, let them know you're open for business.  Meet the guidance counselor, tell them you specialize in adolescent issues. (Obviously, make sure you actually do specialize in adolescent issues.)  Or Family Systems model.  Or divorcing parents.  Etc.


Remember: it's not "why refer to me?" It's, "who else are they going to refer to?"  A doctor who has any sort of emotional connection to you (i.e. met you once) will more likely refer to you than anyone else. 

If you want to work the "best paying patients" angle, then you are looking to work with cash only, reasonably affluent patients.  Ok-- why would they pick you?  Because you went to Harvard?  Because you have a PhD.?  No.  Either a) you in their insurance network so they can get reimbursed; b) they were referred to you.  And so we are back to the beginning: you need a niche, an area of expertise.  I am sure there are patients who would prefer to go to someone who did "Psychodynamic Therapy and General Psychotherapy" even if they simply needed grief counseling, because they'll assume you're better.


I'll write more about this later.