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Family medicine + continue private practice as a psychologist

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I'm a registered psychologist in Alberta (master's level) with a successful private practice, dealing mostly with mood disorders and anxiety.  However, I've always had an interest in medicine. I've interviewed at six different medical schools this cycle and I feel decent about having gotten in somewhere. I originally had assumed psychiatry was the best fit, given my background. However, I am in my early thirties and am not interested in a five-year residency. In addition to this, there are things that interest me in medicine outside of psycomarmachology and psychotherapy, which makes me further inclined to choose family medicine.

My question concerns pursuing family medicine as a career. Would it be ethical/feasible to carry on private practice as a therapist one day per week with family practice four days per week? I like my job enough to want to continue doing it, at least a little bit! But I don't like it enough to do it full-time for life. If it's relevant, I charge $175 per hour as a therapist and book approx 7-8 clients per day with a low no show rate. I would maintain my registration with the college of psychologists and bill through that registration number. 

I am looking to have a discussion on the feasibility of this overall, including ethical issues. One consideration is whether it is ethical to use the same office space for private practice clients and family med patients? I am leaning toward no, because it would be a huge conflict of interest to have my family practice clients become aware of my private practice and profit from them via referral from my own practice. That obviously cannot happen. Is it possible to maintain some separation between both practices if they remain in the same building?

On the other side of things, would it be unethical to advertise myself on my private practice website as a psychotherapist-turned GP who is still practicing psychotherapy and accepting clients via my psych registration number? I would like to be honest about all of my credentials, but it does feel a little odd to me still. I would not want it to be confused for a psychiatrist, or to be seen as leveraging my MD to charge more. Imagine I have a client who decides to come to therapy and likes me enough to want me to be their GP. They know I am a GP because my credential is on my website. Do I say yes, or no, to this request? Would my patients and clients have to remain mutually exclusive categories? I live in a large enough city where it wouldn't be a problem if that were the case. 

Overall, I am leaning toward complete separation of practices, including office space. This is all assuming I cannot bill for psychotherapy as a GP.

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Check with the college and see if its allowed. Seems like a potential grey area. 

If you're already quite successful, why would you even want to do FM? You'll need to see quite a few patients to match the 175$ you currently charge.  Going from a patient relationship situation where you have quite a bit of time...to family medicine might be a bit of a rough transition.  

If you're truly just bored with your current profession and want more to stimulate or change direction that is certainly fine! Monetarily I don't see you coming out ahead, based on what you've written. Likely coming out behind for quite some time.

Billing for psychotherapy as a GP will depend on province, but i can almost gaurantee that it will be far lower than 175$. There is a reason why most GPs don't regularly do psychotherapy, and its not because they dont see the value in it as a modality, it just doesnt make financial sense.

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You probably shouldn't see your family medicine patients as your psychotherapy patients too. The line will be blurred between when the patients have to pay out of pocket and when they don't. You will either end up doing a lot of psychotherapy for free or practicing medicine for free (eg. your patient asks you a medical question when you are doing a psychotherapy session). If you try to bill both you will risk getting complaints from the College about double-dipping

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11 hours ago, JohnGrisham said:

Check with the college and see if its allowed. Seems like a potential grey area. 

If you're already quite successful, why would you even want to do FM? You'll need to see quite a few patients to match the 175$ you currently charge.  Going from a patient relationship situation where you have quite a bit of time...to family medicine might be a bit of a rough transition.  

If you're truly just bored with your current profession and want more to stimulate or change direction that is certainly fine! Monetarily I don't see you coming out ahead, based on what you've written. Likely coming out behind for quite some time.

Billing for psychotherapy as a GP will depend on province, but i can almost gaurantee that it will be far lower than 175$. There is a reason why most GPs don't regularly do psychotherapy, and its not because they dont see the value in it as a modality, it just doesnt make financial sense.

9

You're right that I likely would not come out ahead financially, however as you may have guessed making more money isn't my goal in becoming a physician. I have always wanted to study medicine. There are plenty of other things that are important to me, including job security and greater breadth and depth in what I am doing in my day-to-day work. I feel do not use critical thinking as much as I would like in my current job as treating depression eventually becomes pretty methodical and easy after the first 200 cases. But there are some cases I really do enjoy; there is maybe one out of every five clients with whom I REALLY connect and feel that progress is being made.

I also haven't totally ruled out some other specialties which also have a mental health component (e.g PM&R or Ob/Gyn). 

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10 hours ago, Wachaa said:

You probably shouldn't see your family medicine patients as your psychotherapy patients too. The line will be blurred between when the patients have to pay out of pocket and when they don't. You will either end up doing a lot of psychotherapy for free or practicing medicine for free (eg. your patient asks you a medical question when you are doing a psychotherapy session). If you try to bill both you will risk getting complaints from the College about double-dipping

This is what I was leaning toward as well. It would become too convoluted and confusing, I think. I know GPs have difficulty with patients bringing up more than 1 issue per appointment and I can only imagine how this would be compounded by them bringing up non-medical, psychotherapy problems. Especially in appointments where I would be billing the government.

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As others have said, you would need to check with the college of the province you are thinking of practicing in.  My gut tells me that you won't be able to do this easily.  As a physician you cannot provide a medically necessary service as an out-of-pocket expense.  I am going to assume that psychotherapy is a covered medically necessary service in all provinces. If your patient cannot afford to pay $200/hr for psychotherapy sessions anymore, are you going to stop seeing them? You still have the option of billing through the provincial health insurance plan to see them.  But then how are you going to do this for some patients and not for others? There are a additional complexities to consider as well. I doubt that you can just take off your family physician hat selectively for some patients and not for others.  As a family doctor, most things are considered within your scope of practice.  If you identify unaddressed needs in your patients which fall within your scope of practice, there is likely liability in not addressing it, especially if the patient doesn't have someone else readily available to go to (e.g. another primary care provider). Also, while I have no data to back this up, I imagine that your both your liability and responsibility in providing care to your psychotherapy patients would both increase.  As a MD the buck stops with you (unless you have an appropriate specialist involved).  If there are bad outcomes and people are going to go after you, they are going to go after the physician you, not the psychologist in you.  

I am nearing the end of my psychiatry training.  My per hour billings will generally be less than a psychologist but there are definite benefits to being an MD (in this case psychiatrist) as well. I don't need to work near as hard as a psychologist to drum up business given the massive shortage in psychiatrists.  I can send a fax to the GPs in an area and generally have a full practice within weeks if I'm willing to stay general and not be selective about accepting consults. My earnings are predominately limited by the number of hours I want to work (yet still drastically lower than almost all other types of MDs). I can see patients who otherwise would not be able to afford therapy.  And lastly, I can use medications alongside therapy which is often very effective.

Make sure you give consideration to the possibility of psychiatry if you are interested in becoming an MD.  Being a psychiatrist certainly doesn't limit you to being a psychopharmacologist and it provides you with a lot of open doors.  Your use of other areas of medicine as a psychiatrist is really limited by your comfort level and practicality. Although you're in your early 30's, you still have a lot of potential years ahead of you.  Psychiatrists who do a lot of psychotherapy tend to practice fairly late into life, some will even go well into their 70's.  It's fairly easy on the body, an easy lifestyle and there is a passion for it.  If you're looking at family medicine vs psychiatry before starting medical school you're looking at 6 vs 9 years, when you factor in the length of medical school its not as drastic of a difference.  In many provinces you can also moonlight in your higher years which would probably be very easy to do with a background as a psychotherapist.

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This would be fine. Some of us do CBT already. You would be able to bill the government for those services. In Alberta you'd be able to bill about 200$ for a 53min face to face session.

I see no conflict of interest here at all, but you'd have to be clear with your patients that a booked CBT/pscyh session is for psych and psych only. No checking labs, sore wrists, etc. Or it would drive you crazy.

 

EDIT: As an aside, and keep in mind it's my opinion only, this would be a terrible idea. You already have a job that you enjoy and going through years and years of training is a waste of your precious life. There's more to life than work and to think that you'd have to train and study for 6 more years or more and put your friends and family on hold just makes me nauseated.

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^Nothing wrong with switching careers. Plus it's more like 4 years if he's she's able to get in somewhere close to home -- preclerkship isn't really disruptive.

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16 minutes ago, bloh said:

Preclerkship may not be disruptive at 22, but it is at 30+. Unless you're a still a single child with no responsibilities.

Probably depends on your school. 

The 30+ crowd at our school had no issues with preclerkship. Lectures not mandatory etc.  They universally said preclerkship was easier than the "real world" on a regular basis hah.

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53 minutes ago, bloh said:

Denial in medicine is very prevalent but ok. Believe what you believe.

Not agreeing with you means being in denial?

I'll have to agree with JohnGrisham here. Despite going to a school with grades, preclerkship is ridiculously not time consuming except during exam season.

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1 hour ago, bloh said:

Denial in medicine is very prevalent but ok. Believe what you believe.

I mean, i prefaced with "It probably depends on your school".  Our school was not mandatory attendance for lectures, so that meant only mandatory clinical sessions, otherwise your week was wide open.  Non-standardized exams meant knowing the lecture slides would be enough to do okay-ish.  

Majority of my classmates had plenty of time for involvements, outings, trips etc throughout pre-clinicals, weekend getaways and aside from exam time, nothing really was taking up much time. We had plenty of mornings off etc.  Sure if you want to be going for top 10% of class or something then yes, time is more precious, but if you're fine being below-average or average...there was alot of time in our pre-clinical years.  Obviously child-rearing is difficult and having a family, but if you're not getting involved in clubs, and ECs like a 20 year old is...then it probably balances out?   None of the 30+ crew was involved, they did school, came out for beers every so often and study sessions...but otherwise they already had their family and social circle. 




 

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On 4/16/2018 at 7:25 PM, 1D7 said:

^Nothing wrong with switching careers. Plus it's more like 4 years if he's able to get in somewhere close to home -- preclerkship isn't really disruptive.

I'm a woman :)

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On 4/14/2018 at 10:27 AM, BigM said:

As others have said, you would need to check with the college of the province you are thinking of practicing in.  My gut tells me that you won't be able to do this easily.  As a physician you cannot provide a medically necessary service as an out-of-pocket expense.  I am going to assume that psychotherapy is a covered medically necessary service in all provinces. If your patient cannot afford to pay $200/hr for psychotherapy sessions anymore, are you going to stop seeing them? You still have the option of billing through the provincial health insurance plan to see them.  But then how are you going to do this for some patients and not for others? There are a additional complexities to consider as well. I doubt that you can just take off your family physician hat selectively for some patients and not for others.  As a family doctor, most things are considered within your scope of practice.  If you identify unaddressed needs in your patients which fall within your scope of practice, there is likely liability in not addressing it, especially if the patient doesn't have someone else readily available to go to (e.g. another primary care provider). Also, while I have no data to back this up, I imagine that your both your liability and responsibility in providing care to your psychotherapy patients would both increase.  As a MD the buck stops with you (unless you have an appropriate specialist involved).  If there are bad outcomes and people are going to go after you, they are going to go after the physician you, not the psychologist in you.  

I am nearing the end of my psychiatry training.  My per hour billings will generally be less than a psychologist but there are definite benefits to being an MD (in this case psychiatrist) as well. I don't need to work near as hard as a psychologist to drum up business given the massive shortage in psychiatrists.  I can send a fax to the GPs in an area and generally have a full practice within weeks if I'm willing to stay general and not be selective about accepting consults. My earnings are predominately limited by the number of hours I want to work (yet still drastically lower than almost all other types of MDs). I can see patients who otherwise would not be able to afford therapy.  And lastly, I can use medications alongside therapy which is often very effective.

Make sure you give consideration to the possibility of psychiatry if you are interested in becoming an MD.  Being a psychiatrist certainly doesn't limit you to being a psychopharmacologist and it provides you with a lot of open doors.  Your use of other areas of medicine as a psychiatrist is really limited by your comfort level and practicality. Although you're in your early 30's, you still have a lot of potential years ahead of you.  Psychiatrists who do a lot of psychotherapy tend to practice fairly late into life, some will even go well into their 70's.  It's fairly easy on the body, an easy lifestyle and there is a passion for it.  If you're looking at family medicine vs psychiatry before starting medical school you're looking at 6 vs 9 years, when you factor in the length of medical school its not as drastic of a difference.  In many provinces you can also moonlight in your higher years which would probably be very easy to do with a background as a psychotherapist.

Thank you for this detailed reply. Perhaps I will give psychiatry some more thought. I have worked with a few psychiatrists and their scope of practice seemed limited to prescribing medication, so it's refreshing to hear that this would not be a necessity. 

What you mentioned about psychiatry vs psychology is so true and in fact one of the reasons I have applied to study medicine. I work very hard advertising myself in private practice and it can be exhausting and stressful knowing that my salary hinges so much on self-promotion. As you said, the ability to bill the government is a nice thing to have.

Do you think you will open up a private practice, then, as a psychiatrist?

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On 4/18/2018 at 5:45 PM, Snowmen said:

Not agreeing with you means being in denial?

I'll have to agree with JohnGrisham here. Despite going to a school with grades, preclerkship is ridiculously not time consuming except during exam season.

You're welcome to come and report back in 2022, medical student.

I never once mentioned "time-consuming". There's more to preclerkship than that. The uncertainty about the future, stress, and having your life out of control all adds up over the years. It may not seem like it in the moment, when you're there observing other people taking blood pressure but I guarantee that the journey adds significant burden over time.

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On 4/20/2018 at 1:57 PM, bloh said:

You're welcome to come and report back in 2022, medical student.

I never once mentioned "time-consuming". There's more to preclerkship than that. The uncertainty about the future, stress, and having your life out of control all adds up over the years. It may not seem like it in the moment, when you're there observing other people taking blood pressure but I guarantee that the journey adds significant burden over time.

 I agree with the last paragraph - but I think that applies to  everyone in their own way too regardless of child rearing! Uncertainty and stress definitely apply, I will say anecdotally that most of the parents in my cohort are going for FM(and various +1s) due to the inherent flexibility and control it has historically had. May not be the same in the future, but its likely the safest and shortest path still. So perhaps a bit of self selection in that manner, to somewhat reduce the stress and uncertainty (and if matched somewhere less desirable, its a much shorter duration etc)

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Unless you get into medical school in Alberta, and even if you do, you are most likely losing ground financially at least during medical school and residency, and I'm not sure you'll end up doing much better than you are now. Do you think the work as a doctor would be that much more satisfying that it justifies an investment of at least 5-6 years of your life?

I'm a non-traditional med student myself and went into medicine from another career. I would NOT do it again and I would advise anyone going this route, especially if you're over 30, to think very very hard and carefully about what they're doing, especially if you end up having to move across the country for it. Do not underestimate the psychological, emotional and financial toll this will have on you and others in your life. For my part I way underestimated how much I enjoyed having an income, friends, being able to do things that other ordinary adults do at this stage of life, and how much I would give up.

I have now matched into a residency which is requiring me to move yet again to a city where I don't know anyone and it's taking an incredible toll on me. I just can't get a break. But now I'm in debt, I've already given up several years of life and income to get here, and either I walk away and try to get back into another career or I keep going and try to make something of all the time and money I've invested. Maybe, maybe this might be worth it in the end, I don't know, but by the time I'm done I'll be almost a decade older and will have missed out on so many things people my age will have enjoyed.

So think carefully, please. You have a lot of good things going on. Billing $175 for therapy? You're basically making a physician's income already. Why would you make so many sacrifices in order to... make essentially the same income, while having to follow the rules and standards of a much more bureaucratic profession?

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I really agree with much of what Shematoma said.  

OP, I think you really need to ask yourself why you want to do this.  175$/hr is incredibly successful for a therapist--like I know psychologists, and that is so successful compared to the ones I know it really is almost hard to believe.  I RARELY say this (because medicine is usually a better financial option)--but in your case I really don't see how its worth it.  Say you do family--you have 3-4 years of negative income, then 2 years of resident income.  You probably would not make the 5-6 years of lost income back over a career as a GP if you are pulling 175/h.  Plus it will be 5-6 years of stress, relative uncertainty (compared to your current situation), long hours--what is the point?  Your initial post is not that convincing.  I'm not trying to be condescending, but you seriously need to ask yourself if you just want to be a doctor because it sounds cooler to say you are an MD.  

To answer your initial question, no you cannot just go and practice as a psychotherapist and charge for it.  You need to do it as an MD if you are a practicing MD.  You will make less than 175/h (very likely) for GP psychotherapy.  

Maybe this all makes more sense if you want to go into psychiatry.  

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On 4/22/2018 at 4:18 PM, shematoma said:

I'm a non-traditional med student myself and went into medicine from another career. I would NOT do it again and I would advise anyone going this route, especially if you're over 30, to think very very hard and carefully about what they're doing, especially if you end up having to move across the country for it. Do not underestimate the psychological, emotional and financial toll this will have on you and others in your life. For my part I way underestimated how much I enjoyed having an income, friends, being able to do things that other ordinary adults do at this stage of life, and how much I would give up.

As another older student / resident I agree with all of the above. I entered medical school in my mid-thirties, and am now part-way through a royal college residency. Knowing what I know now, I wouldn't have done it. I wouldn't say I regret it, but the psyco-emotional cost is high. You mentioned wanting more critical thinking aspect of your work... in my experience, there is a lot less of that in medicine that most outside of it think, and a lot less than doctors themselves think they do. The vast majority of the learning process is more about memorization and pattern recognition than critical thinking.

 

Pre-clerkship is easy and fun. Clerkship is a pain in the ass, and residency more-so. FM seems to be a better environment, judging from my friends who have done it.

 

Just be prepared to not be treated as an adult for the next 6-12 years until you finally finished and get your certification(s).

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