PRIVATE PRACTICE
By: Peter Jay Stein, MD, MA
For those contemplating establishing a prosperous, private, psychiatric practice, such an accomplishment can be powerfully satisfying. Several factors help to keep a practice flowing, wherein one can maintain one's interest, income, and energy.
Being one's own boss has immense advantages, the greatest of which is that one cannot get fired. In some ways, one's patient is one's boss, upon whose fee one depends, and the patient can fire the clinician if dissatisfied with the services rendered. There are other hurdles perhaps not found with employee status, such as maintaining one's own malpractice, disability, health and life insurances. The home office is especially advantageous in countless ways, e.g., in the absence of commute time, flexibility of hours, availability for all sorts of domestic issues, tax advantages, and simply being adjacent to all the comforts of home. There can be spontaneous availability for a patient virtually any time day or night, and conversely, one can feel free to limit one's hours on any given day, week, or week-end.
Treating a diverse class of patients, including individuals, couples, and families, with an array of diagnoses, widens one’s repertoire, and promotes learning and eventual mastery. With a heterogeneous practice, the tools of psychodynamic fundamentals, psychopharmacology, and medical/neurological knowledge help to assess most clinical situations. These tools, however, must be grounded in adequate self-knowledge, including an awareness of one's unconscious personality trends, a willingness to frequently assess one's own emotional status during and after a session, a determination to improve one's capacity for sustained empathy, and feelings of comfort and friendliness towards oneself and others. It is essential to eventually acknowledge one's limits in skill and tolerance, in order to recognize which patients or diagnostic categories may not suit one's tastes and/or abilities.
For the growth of one's practice, the development and maintenance of referral sources are crucial. By one's availability, responsiveness, and reliability to the referral source, with timely communication of findings as well as the expression of gratitude for a referral, one can nurture future referrals. Engaging in split treatment, i.e., doing medication management while the patient has a social worker or psychologist as the 'primary' psychotherapist, offers certain advantages and pitfalls. Because there are not enough psychiatrists to treat every patient, collaborating with the non-MD, non-psychiatrist clinician is a practical necessity which gives the psychiatrist an often welcome alternative to conducting 45 minute psychotherapy sessions. There are also the advantages of connecting with a diverse array of clinicians with different perspectives and treatment approaches, while generating a perpetual referral stream.
A useful rule of thumb regarding malpractice related to split treatment, is to recognize that the 'medication' patient is the psychiatrist's patient, regardless of whomever else may be involved in the patient's care. As with all patients, one must be thorough and vigilant. One's progress notes must systematically document the various areas which may herald problems, and should include the name of the patient; the date and type of visit; the patient's mental status, medical status, and medication status; the patient's awareness of the risks, benefits, and alternatives of treatment; the patient's level of cooperation and insight; the level of participation of family members, if applicable; the patient's responses to treatment; the patient’s level of dangerousness to self or others; diagnoses; and treatment plan. Do not forget to sign all progress notes and chart entries.
Supervision is essential for a successful private practice, as it helps to dilute unhealthy pride, reduce anxiety, and build confidence. Personal psychoanalytical psychotherapy enhances the clinician’s emotional freedom and exposes blind spots. Peer supervision, continuing medical education, and participation in one’s professional societies serve to enhance one’s visibility among colleagues and within the community. As a final point, one must preserve and nurture one’s private self, to find a balance with one’s work that does not sacrifice personal and family relationships, adequate periods of rest, recreational outlets, and other creative endeavors.