Private Practice Olio

[smalltownpsych]

Been awhile since I updated. Mainly because the business is keeping me very busy. My two interns have completed their degrees and this will help with getting them more cases and justifying their fees. My IOP/aftercare type of program is doing ok and I have four clients in that with one more starting next week and with the new case I am handing it off to my employee so that will be a good thing. Trying to figure out how to pay my newly graduated therapists is the next issue to address.

Last month we generated 25k in revenue and that was with me taking a week vacation. Last year with that vacation, revenue dipped to 16k so progress there. At this point it is clear that we are going to be able to stay afloat and that our business model seems to be working, but we are not exactly going to get rich quick. Some of the reason for that is that I am a better clinician than I am a businessman, but I am okay with that because I think I am good enough at that part and our edge in providing superior clinical services is what I’m selling anyway.

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[PikminOC]

Been awhile since I updated. Mainly because the business is keeping me very busy. My two interns have completed their degrees and this will help with getting them more cases and justifying their fees. My IOP/aftercare type of program is doing ok and I have four clients in that with one more starting next week and with the new case I am handing it off to my employee so that will be a good thing. Trying to figure out how to pay my newly graduated therapists is the next issue to address.

Last month we generated 25k in revenue and that was with me taking a week vacation. Last year with that vacation, revenue dipped to 16k so progress there. At this point it is clear that we are going to be able to stay afloat and that our business model seems to be working, but we are not exactly going to get rich quick. Some of the reason for that is that I am a better clinician than I am a businessman, but I am okay with that because I think I am good enough at that part and our edge in providing superior clinical services is what I’m selling anyway.

Do your interns also provide superior clinical services?

 

[WisNeuro]

Do your interns also provide superior clinical services?

Is there a question behind the question?

 

[PsyDr]

Is there a question behind the question?

I’m sure you know. But I’ll cal it out more.

It’s an interesting argument regarding whether one’s experience enhances one’s clinical effectiveness. Post doc interns are less experienced. Are they less clinically effective? Or are they more up to date, and thus provide more effective treatment?

It’s like asking if the new interventional radiologist is better at gamma knife because he was trained in it, or saying the established interventional radiologist, who learned gamma knife in less structured settings, is better because he/she has more experience in general. And does that change any malpractice standards? Should patients being treated by residents get a reduction in bills?

 

[Therapist4Chnge]

As with most things in healthcare, the newer post-doc is probably pretty solid w the updated research and interventions, so working with "Horse" cases they likely will do fine to well. Will they do as well with a "Zebra" case...that is where the extra "experience" is likely needed. Just my pure speculation.

 

[PsyDr]

As with most things in healthcare, the newer post-doc is probably pretty solid w the updated research and interventions, so working with "Horse" cases they likely will do fine to well. Will they do as well with a "Zebra" case...that is where the extra "experience" is likely needed. Just my pure speculation.

It's a weird thing. Socially, people prefer older providers due to the belief that experience=better. But we also know that cognition declines as we age. And society protects against "age discrimination", that only applies to the older ages and not the younger ages.

 

[Sanman]

It's a weird thing. Socially, people prefer older providers due to the belief that experience=better. But we also know that cognition declines as we age. And society protects against "age discrimination", that only applies to the older ages and not the younger ages.

I think that there is a benefit to wisdom as well. While a younger clinician might be more familiar with the latest technique, the wisdom to sometimes leave things alone matters. I learned more of what not to do from early career supervisors/mentors than what to do.

 

[SikeThatsTheWrongNumber]

This study found a small but significant decrease in clinical outcomes as a function of therapist experience (more experience, worse outcomes). The effect remained even when controlling for potential confounds such as baseline severity, length of treatment, therapists’ initial level of experience, caseload size, rates of early termination, etc.

 

[WisNeuro]

This study found a small but significant decrease in clinical outcomes as a function of therapist experience (more experience, worse outcomes). The effect remained even when controlling for potential confounds such as baseline severity, length of treatment, therapists’ initial level of experience, caseload size, rates of early termination, etc.

I know people love this study, but people also over interpret it. Only outcome is the OQ-45, and, like everything Wampold, he collapses everything together. This would be stronger with actual random assignment, breaking out diagnoses, measuring more meaningful functional outcomes, and more tightly controlling years of experience. In this study it's a little disingenuous to say that the less experienced therapists did better. These were therapists receiving active supervision for their clinical work, as this study took place at least partially within the context of a training clinic. It's in interesting question, but I don't think this study comes close to answering it, all it does is suggest we need further work done to find support for a hypothesis.

 

[Sanman]

I know people love this study, but people also over interpret it. Only outcome is the OQ-45, and, like everything Wampold, he collapses everything together. This would be stronger with actual random assignment, breaking out diagnoses, measuring more meaningful functional outcomes, and more tightly controlling years of experience. In this study it's a little disingenuous to say that the less experienced therapists did better. These were therapists receiving active supervision for their clinical work, as this study took place at least partially within the context of a training clinic. It's in interesting question, but I don't think this study comes close to answering it, all it does is suggest we need further work done to find support for a hypothesis.

I have not read the details of the study, but I am curious if this is replicated around the world. In the U.S., we are paid to see patients and not for outcome quality. As you get older, this will certainly bias the sample.

 

[WisNeuro]

I have not read the details of the study, but I am curious if this is replicated around the world. In the U.S., we are paid to see patients and not for outcome quality. As you get older, this will certainly bias the sample.

A trainee under close supervision, essentially having two therapists on a case, will also bias the results.

 

[PikminOC]

A trainee under close supervision, essentially having two therapists on a case, will also bias the results.

In the private practices I see, supervision is minimal. The supervisor therapist is seeing a full load of clients themselves

 

[PikminOC]

As with most things in healthcare, the newer post-doc is probably pretty solid w the updated research and interventions, so working with "Horse" cases they likely will do fine to well. Will they do as well with a "Zebra" case...that is where the extra "experience" is likely needed. Just my pure speculation.

Yes and you never know when a horse turns into zebra case.

 

[WisNeuro]

In the private practices I see, supervision is minimal. The supervisor therapist is seeing a full load of clients themselves

How do you know how many hours of supervision is happening in a multitude of private practices? Just out of curiosity. I hear people make certain statements sometimes, and the only way a person would know is if they were embedded within that clinic, for the most part.

 

[PikminOC]

How do you know how many hours of supervision is happening in a multitude of private practices? Just out of curiosity. I hear people make certain statements sometimes, and the only way a person would know is if they were embedded within that clinic, for the most part.

The therapists there tell me. They say they sometimes have supervision by phone. And the owner is on vacation alot and unreachable. The therapists are there for their 2000 hours and afraid to rock the boat

 

[WisNeuro]

The therapists there tell me. They say they sometimes have supervision by phone. And the owner is on vacation alot and unreachable. The therapists are there for their 2000 hours and afraid to rock the boat

And you hear this about multiple practices? Plural? You're frequently having these kinds of conversations with multiple therapists for some reason?

 

[PikminOC]

And you hear this about multiple practices? Plural? You're frequently having these kinds of conversations with multiple therapists for some reason?

This one has over 8 therapists there.

 

[WisNeuro]

This one has over 8 therapists there.

And you've talked to all of the therapists there, as well as therapists from other practices about this?

 

[smalltownpsych]

It is not unusual and maybe even typical to have minimal supervision out in the private practice and the community mental health world. This is especially so when comparing to the amount of supervision that psychologists get during our training. The quantity and especially the quality of my own personal supervised experience surpasses anything Ive come across since getting my degree back in 2008.
That being said, part of my model is to provide excellent supervision to my new therapists and have people that appreciate and value me sharing my knowledge and experience. As @WisNeuro said, the patients are getting my support too. Since quite a few of my patients are professionals, they get this and are seeking us out because we are better than the typical and are willing to pay for it. I learned pretty early on that throwing out jargon and not having knowledge of the evidence base is not going to get you very far with a physician or attorney for example.

 

[smalltownpsych]

Insurance based practice is totally different animal because the margins are really really tight. No way that I could do what I do if I was running an insurance based practice. I am intentio trying to do things differently and be creative and have that freedom. My question is not could I do more if I had more financial resources, it is more often, given unlimited financial resources for a case, what can we do? The answer to that points to financial barriers not being as much of the obstacle to effective mental health treatment as I used to think.

 

[PikminOC]

It is not unusual and maybe even typical to have minimal supervision out in the private practice and the community mental health world. This is especially so when comparing to the amount of supervision that psychologists get during our training. The quantity and especially the quality of my own personal supervised experience surpasses anything Ive come across since getting my degree back in 2008.
That being said, part of my model is to provide excellent supervision to my new therapists and have people that appreciate and value me sharing my knowledge and experience. As @WisNeuro said, the patients are getting my support too. Since quite a few of my patients are professionals, they get this and are seeking us out because we are better than the typical and are willing to pay for it. I learned pretty early on that throwing out jargon and not having knowledge of the evidence base is not going to get you very far with a physician or attorney for example.

Yes this is just very different from the residency that physicians get as there is a lot of supervision. And under the acgme, many requirements that have to be followed to maintain certification. This is why to me, the "supervision" therapists are getting is very surprising.

 

[PikminOC]

I’m sure you know. But I’ll cal it out more.

It’s an interesting argument regarding whether one’s experience enhances one’s clinical effectiveness. Post doc interns are less experienced. Are they less clinically effective? Or are they more up to date, and thus provide more effective treatment?

It’s like asking if the new interventional radiologist is better at gamma knife because he was trained in it, or saying the established interventional radiologist, who learned gamma knife in less structured settings, is better because he/she has more experience in general. And does that change any malpractice standards? Should patients being treated by residents get a reduction in bills?

As a resident physician I certainly did not know enough. That's why we had the training, then board certification. I had both an oral and written exam for ABPN board certification. It took me years after that to continue to improve, and I have 150 CME every three years and additional requirements to complete to keep it. Including an exam every ten years. This keeps me up to date on the newer treatments.

 

[biscuitsbiscuits]

What are your experiences with the following paid directories? Any of them worth the monthly fee?

• Mental Health Match
• Zencare
• Therapy Den
• Zocdoc
• Others?

They're all around a price where one consistent client from each would cover the yearly cost, but I still have this feeling that they aren't worth it in addition to professional referral sources and psychology today. My caseload is about as full as I want it to be at this point, so this is mostly to make sure I can maintain these numbers.