Hi, everyone. Thanks so much for joining us for this afternoon's session. I'm Denae Duracko, addiction psychiatrist, Cleveland, Ohio. I am Chun Tong. I'm an addiction psychiatrist in New Jersey. And we are chair and co-chair of the membership committee for AAAP and putting on this workshop today to talk to some of our esteemed colleagues in different areas within the field of addiction psychiatry, talk about their careers, kind of how they got there. And then I'm hoping that this will be a very interactive session. I've got about half the time for Q&A. So we'd love to hear what you guys want to know about working in the field. I have some prepared questions. Hopefully, I won't need to use any of them because everyone else will be chiming in with what they want to learn about. So I'm going to introduce our panel, and then we're going to let them speak for a few minutes about their careers so you guys have an idea of kind of what they do, what they've done in the past. And then we'll turn it over to Q&A, all right? Let's get the clicker. So no disclosures for this workshop. Some objectives that, you know, learning about the careers and opportunity for you guys to ask questions. If you guys want to quickly pull up this survey, this is going to ask you about what you're considering in terms of maybe career areas and then some things you'd like to learn about today. So if we do need to direct some questions, we can direct them towards ones that you guys want to learn about. I'll leave that up for another few seconds. There's a lot of noise coming in. All right. All right. So everybody, I see a few phones still up. I'll let you guys do this. Yeah. We'll put it back up at the end too, so. All right. So here's our five panelists today. And do we click the next one? No. Okay, so today we have a psychiatrist who is in, they're all in somewhat of a different career trajectory. And when I was a trainee, I also realized that there's a lot of things you can do when you become a psychiatrist and later on become addiction psychiatrist, or you may know some people with more than one board. And I also really want to know what people do with their fellowship training. After a year, they really opened a lot of doors. And it will be easier if I can talk to these people who've been through these doors. So I was able to have Christine, Dr. Christine LaGroda, to come in. She is addiction psychiatrist. She, in doing my training, I met her in Bronx VA and she was doing her work with the veteran, which is very, very inspiring. I have Dr. Robert Ramos. He is a addiction psychiatrist working in private practice right now. And he gone through different places and does a lot of things. And we used to go to the same residency program together. So that's how we know each other. We also have Dr. Lauren Grawert. Yes, okay, I got it right. Addiction psychiatrist and the chief medical officer at AWARE Recovery Care. Looking forward to hearing about that program. Dr. Ayanna Jordan, who's the Barbara Wilson Associate Professor of Psychiatry in the Department of Psychiatry and Population Health at NYU Grossman School of Medicine and the PI of the Jordan Wellness Collaborative, a research collaborative there. And then Dr. Jose Vito, who is the AAAP member at LARGE, clinical assistant professor at NYU, and an outpatient psychiatrist for the Office of Mental Health in the state of New York. So I'm going to turn the mics over to them. Whoever, I think we have Dr. Grawert first. We went in alphabetical order. You're all so esteemed that we couldn't put you in any other kind of order. So I'll let you go ahead and start. We'll time you for like five to seven minutes. I'll give you a one-minute warning, and then we'll hear from everyone, and then turn it over to the audience, okay? Thanks. Can you guys hear me? I get to talk about my favorite topic, which is myself. So awesome. Yeah, so I'm Lauren. I'll just give a brief overview. I went to medical school, psych residency, and did my addiction psychiatry fellowship at the Medical University of South Carolina. Our esteemed program director is in the room right now, Dr. Karen Hartwell. And so when I came out of fellowship, I really didn't see myself doing just pure addiction work. But my husband and I ended up moving to the Washington, D.C. area, and I began working at Kaiser Permanente of the Mid-Atlantic. For those of you not familiar with Kaiser, it kind of operates as like Chick-fil-A's. There's like independent regions. It's largest in California. The second largest is in the Mid-Atlantic. They had no addiction psychiatrists at the time, and they said, we're looking for somebody who can start a buprenorphine induction program outpatient and an ambulatory alcohol detox program. And so for the first 10 years of my career, I helped to build an outpatient ambulatory alcohol detox program, outpatient buprenorphine induction program. And then, of course, when COVID hit, we turned that all virtual overnight, which was lots of fun. In 2019, I became the assistant chief. And then shortly after, the chief of psychiatry and addiction there. Also fun, becoming chief of the department like months before COVID hit. Required lots of, I think, maneuvering of personnel and changing workflows overnight. But really enjoyed my time there. Left Kaiser after building those two programs in 2022. Did private practice for about a year. And then got a call from a former Kaiser colleague saying, do you want to, are you interested in being the CMO of a private equity-backed addiction group? And of course, I said, no, that sounds terrible. Private equity, money for profit? Uh, I don't think so. And he said, well, just take a look at it. It looks really interesting. So, AWARE Recovery Care, where I'm at now, which I took the role, does comprehensive in-home addiction treatment. It's a 12-month-long program. We send certified peer recovery advocates into the home twice a week with certified peer recovery projects they do with patients. Our patients get a case manager. They get a psychotherapist. They get a family therapist for any identified ally. They do, we do family psychoeducation. And then the part I'm most involved with, we supplement that with virtual MOUD, co-occurring disorder treatment, as well as we have a virtual ambulatory detox program. I think we might be the only ones in the country doing that all virtual. 1.7 level of care for ACM. So, I've been there the past two years. What I will say, it is, it's a private equity-backed company. That's really different from academic medicine. It's, like, where business and medicine meet. And so, I think what's been interesting about it for me is I'm on board calls where they're talking about EBITDA, or where they're talking about run rate, where they're talking, I'm seeing your face, you're like, no clue. I used to keep my phone out and, like, Google, like, acronyms constantly. What is EBITDA? What is run rate? But it's really been a fascinating learning curve to learn about the business of medicine. My role, really, as the CMO, is to make sure that patient clinical care is never compromised for financial profit. And that is shockingly harder than you might think. My role, you know, I do a lot of, kind of, patient reviews. Can this person be admitted to our program? There, in the private equity world, there's incredible financial pressure. And so, but my role, really, is patient care has to come first. The other thing that's cool about my role is I do a lot of speaking. I travel around the country, doing a lot of speaking, mainly to other physicians about SUD treatment. I have a blog where I do medical writing, mainly about addiction advocacy. It's called Hot Topics in Healthcare on LinkedIn. And so, I think the experience has really shown me that there's so much you can do as an addiction psychiatrist. With some of the speaking stuff, if you like speaking, if you like advocating, if you're good at it and you do it once or twice, people will start asking you to do it again. People will start paying you to do it. And you're like, I don't need to be paid for this. But it's really been a great way to, I think, just amplify addiction advocacy. Because I live right outside of Washington, D.C., I do a lot of stuff on Capitol Hill as well. So, I'm involved with AAAP, of course. I'm also in ACM. We did an ACM Hill Day where we were advocating for the passage of MOTA, advocating for the passage of the Treats Act. And so, that's a little bit about me. But I think the main message I want to convey to you, if you're wondering what to do, is there's so much more beyond just traditional academic medicine. And it's really cool to learn more about the business of medicine. I think, unfortunately, I'm going to get my soapbox for a second. There's this fallacy that if you're a physician, you can't be interested in money. Or it's sinful to be interested in money. Which we would never say about a lawyer or Wall Street. But really, those things can coexist. And they should coexist. So, we can advocate for ourselves, for salaries that make sense. I do a lot of contract negotiation with payers. But that has helped me be a better contract negotiator for myself. So, long story short way of saying, it's not bad to want to help patients and make the world a better place and make money. Those two things can coexist. And I think we should say more of that as physicians and push back on the notion that if you're interested in economic security, that that's at odds with being a physician. It's definitely not. So, that's a little bit about me. Perfect in the one minute. All right. Is this on? Yeah. Hi, guys. I am so happy. Because this is my last talk. I have four talks. So, I'm really, really pumped about that. But I am going to do just an arc of my career trajectory. And I want to start with saying that the first time that I applied to medical school, I did not get in. And that is a big deal for me to say publicly. Because there was so much shame that I held for a long, long time. But for me now, being like mid-career, it's important for me to just be very authentic and tell my truth. But also, for you all to see, like, this finished product, right? Had some really circuitous roots. And also, too, I didn't start out wanting to be an addiction doc at all. And definitely not a psychiatrist. So, just that's honest. So, I went to a historically black college and university, the real HU, Hampton University. HBCUs are the culture. And it was such a lovely point in my life in terms of just being around all black people, never having to worry, like, am I smart? Who are you? Do you have the skills? Like, it was lovely. And the first kind of real disappointment for me was when I applied and didn't get in. So, after that, I did a post-baccalaureate program at the National Institutes of Health. At that time, I thought I was going to do infectious disease and be an infectious doctor. I met Anthony Fauci. I had no idea later he would be a rock star. He was so, so kind. He was my boss. I took a job at the National Institutes of Allergy and Infectious Disease. I just want to pause there because I think how we interact with people matters, right? Obviously, he had no idea that he would have such an impact on my life. But I think about how kind he was, how encouraging he was, especially at that time in my life. And one of the things that I try to be is an empathic leader. So, that really informs the type of leader that I am. Skip to, I ended up applying to an M.D. and a Ph.D. program, partly because I've always loved science. I was working in a science lab. I loved it. I didn't realize that you could do both together. One of my mentors at NIH said, Aiyana, you have an ability to connect with people and you kick ass in a lab. I think you should do both. So, shout out to women. I had a woman director, Dr. Betty Diamond. I love her. She accepted me into the Albert Einstein College of Medicine at Yeshiva University in New York. I love New York City. I'm so grateful. And started what would really just change the trajectory of my life. So, you know, yes, I'll just say it was a very interesting place. And through that experience, I was married, got a divorce, became suicidal. And I was walking across the street one day, leaving my apartment, going to the lab. And I said, if a bus hits me, like, I could care less. Like, I'm over it. Within that experience, I had an interaction with a therapist, was referred to a psychiatrist, and it literally changed my life. In terms of, one, who gets to see someone, who's immune to, like, who's determined as having mental illness or not. I never saw myself as being sick. But also how much care went into those interactions and how that helped me to really put my path on what I wanted to do. So up until that point, I was going to do, like I said, medicine, infectious disease. My PhD is actually in immunopathology. A lot of people don't know that. And once I was in therapy and treatment, I was like, oh, this is what I want to do. I want to help people really find their truth. And I did my psychiatry residency in the South Bronx. It was all white docs, all Latinx patients. And they kept coming back and back and back. And they only wanted to see me, and I was a medical student. And so I was like, there is a real need for people who are interested in medicine, psychiatry in particular, who are from diverse backgrounds. But also who are, like, really practicing culturally informed care. And this is before social determinants was a thing, right? So my journey was very much like I want to study how to bring about culturally informed care in psychiatry. That wasn't really a field. My mentors were like, what are you talking about? You are not well. Like, you cannot do this. All of your work has been in infectious disease. All your papers, your PhD is in that. And I said, this is what I want to do. So skip to after that, I went over to Yale to do my training in psychiatry residency because Yale, out of all the, like, large academic programs, they were the ones that allowed me to just be me. To start a research path and see patients and what I wanted to learn. So I did that. And ended up staying on at Yale for addiction fellowship. And, okay. I have a minute. We can ask questions. But during the pandemic, I had a lovely life in Connecticut. And then I woke up and I was like, I'm not a middle-aged white woman. No offense. But I was like, I have to get back to the city. And I want to have an impact there. So I got recruited to NYU to really help with their co-occurring program. But also to develop my lab that really focuses on how to increase access to care, evidence-based treatment for people in their communities. Right? Most folks are never going to see an addiction psychiatrist. A lot of people cannot afford to go to programs that cost a lot of money. And so how can I bring about care and use community to do so? So that's what I do now. I employ mostly black and brown folks in my lab. The lab that I run is called the Jordan Wellness Collaborative. I employ people who use drugs. I think that's pretty badass. I employ women scientists. I also think that's pretty badass. And I also get to see patients. I do a lot of speaking. My highlight was me and Anderson Cooper and being on CNN. So yeah. Yeah. And now I get to work with the NBA in treating and educating basketball players so that they don't get involved with drugs. So lots to talk about, lots to say. But that's my story. Thanks. I'm done. I'm done. Thank you. Thank you, Dr. Jordan. Next up we have Dr. Lagrada. Oh, she's got the mic. Perfect. Hi, everyone. Is this on? My name is Christy Lagrada. And just a little bit about my background. I went to medical school at SUNY Upstate Medical University in Syracuse. And then I did my psychiatry residency at University Hospitals in Cleveland. And I came back to New York to do my addiction psychiatry fellowship at what was then Mount Sinai, St. Luke's West, which is now Mount Sinai Morningside and West. And now I work as an addiction psychiatrist at the Bronx VA in New York. When I was a fellow, it was obviously a one-year fellowship, eight of the 12 months were at the Bronx VA, which is kind of what piqued my interest in working there. After fellowship, I explored the different opportunities in New York City. I looked into private practice. I looked into the different academic institutions in New York, and obviously eventually ended up at the VA. A lot of that was because of my fellowship and the people who I worked with there and the experiences that I had, which I'll get into a little bit. So now at the VA, I have a couple different roles. First, just my clinical work, which is an outpatient, just like a regular outpatient addiction clinic. At school, we have a methadone clinic embedded within our outpatient clinic. And a lot of the work that we do, which I really enjoy, is we don't have barriers of you have to see people for a certain amount of time. You can only see people once a month. We can really see people for as long as we want. We can see people as often as we want. Another thing that I really enjoy about it is that we don't have to deal with insurance companies. And that if we want to give Vivitrol to somebody, we just say, go down the hall and get Vivitrol. There's nothing that gets in the way of us providing that clinical care. If we want to give Sublocade, same thing. There's no prior authorizations, no insurance companies. It's cool. Go two doors down. So that's the clinical part of my work. I also am our site training director for psychiatry residencies. So we have four different residents from four different psychiatry residencies who rotate through the Bronx VA in different capacities. So we have Mount Sinai Hospital, Mount Sinai Beth Israel, Mount Sinai Morningside and West, and Bronx Care. They rotate through our inpatient unit, through our addiction unit, our geriatric unit, kind of all of our outpatient units, and then do all of the call, overnight call in the emergency department in our inpatient unit. And so as site director, I kind of act as a liaison between the different psychiatry residencies and the Bronx VA, and am in charge of the education of the residents at the VA. So that includes, like, lectures, supervising, teaching, and really just helping with any problems that may come up that residents might have and working to troubleshoot any issues that come up with the residents. I'm also associate program director for our new VA track. So we're actually starting in July of 2025. We're going to be opening a new VA-specific residency track through Mount Sinai, Morningside, and West. It will be four residents per class, so a total of 16 residents. And we're actually interviewing and all that for that class coming up. And the last thing that I do there, which is kind of cool, is the Bronx VA is really involved in psychedelic research. And so we just completed a comparative effectiveness study looking at MDMA for PTSD. So the study looked at two versus three sessions of MDMA-assisted psychotherapy for PTSD. So in that study, I worked as a study physician and a study therapist. So as study physician, just seeing, like, if people met eligibility criteria and working with people to come off of their SSRIs or other psychiatric medications and making sure that was done safely and that people were doing OK during that process. And then as study therapist, actually doing the MDMA studies, the MDMA sessions, which was really a really rewarding experience. So that included doing the preparatory sessions, doing the actual MDMA sessions, and then the integrative sessions afterwards. So really doing a lot of different things there. I also have a private practice based in the suburbs as well, but that's a much smaller part of what I do. And if anyone has questions about working for the VA, I'm happy to answer them. There's a lot of benefits that we have. I think a big thing is, as I said, the clinical work. There's really very few barriers to the clinical work. You can see people, treat people how you want to. And then on the other side of things, like work-life balance, the VA has its own loan repayment program in addition. So I'm actually in the public service loan forgiveness. But they also, in addition, have their own loan repayment program called the Education Debt Reduction Program. Again, I'm happy to talk more about that if people have questions on it. I said work-life balance, time off, all that good stuff. And surprisingly, salaries were competitive with most other academic places in New York, which was kind of altogether a really good package. So I'm happy to answer more questions about the VA if people have them. Thank you, Dr. LaGrada. All right, next up we have Dr. Reimowitz. Hi, I'm Robert Reimowitz. I'm from Poland. And I came to the United States in 2012 to go to medical school on a visa. I knew right away that I wanted to be a psychiatrist. And I really wanted to work in substance use disorders afterwards. I went to Rutgers for residency. And I really enjoyed residency. I really thought I wanted to get a job at an academic medical center after I completed fellowship. Went to UCLA for fellowship. And while I was there, I was offered a number of sort of private practice jobs on the side, which I eagerly accepted. And they were a lot of fun. And I really, really have enjoyed working with rehabs and with private practice patients. But unfortunately, at the close of my fellowship, I was unable to find an academic addiction psychiatry job that would provide a J-1 visa. And I had to get a job in order to be able to obtain just a J-1 visa waiver to remain in the United States for the next three years. I was fortunately able to find a J-1 visa waiver in addiction psychiatry in Phoenix, Arizona. And I got a job working for a private company, private for-profit company, which was a very, very interesting experience. The compensation was fantastic initially. Top month, I made over $50,000 after taxes. A bad month was $30-something thousand after taxes. But it was also a pill mill. And there was all kinds of issues that went along with that. And I was wondering, how could I possibly be compensated so well for seeing Medicaid patients? And then we got purchased by a private equity firm. And it came out that there were probably some issues with billing that allowed us to be paid so well. And compensation there just really tanked. It's still pretty decent. But it's really not what it was previously. The patient workload continues. I see sometimes, on a regular day, 30-something patients. Back in the day when things started over COVID, it was close to 50 patients a day. And it's really just one patient after the other, back to back. So it's very difficult, unfortunately, and a lot of work. And in addition to that, I have my private practice on the side. So I'm generally working on weekends as well, usually working from 9 AM in the morning to 8 AM on a slow day, 10 PM on a busier day, and sometimes taking one day off a week. So unfortunately, that was a lot of work. But the private practice side, I have to say, has been really a wonderful experience to be able to work with patients and really be able to help them. The company that I work for now, I am going to be able to resign that job and accept an academic position in January now that I've completed my J-1 visa waiver. But I would say I would be a little bit cautious in accepting a job at a for-profit place if you are not the person actually taking all those profits. If you're working for other people and you're just trying to extract a lot of money out of patients or out of a medical system, it might not be the best job. It might be something that you might want to look into a little bit more. Unfortunately, the workload has been very high, too, just between working two jobs. So over the last three years, my wife and I took two one-week vacations. We had a three-day honeymoon. And that's about it, unfortunately. But compensation has been good. So there's a little bit of balance to that. But there's no work-life balance whatsoever, unfortunately. Other than that, it's been a very, very boring job because I don't really have any colleagues who are physicians or anything of that sort. It's generally nurse practitioners. And I work entirely remotely, so I actually never see them. So I would say just think twice about taking a job, not in your own private practice. My own private practice, I can only see fantastic things about it. If I didn't have to have a job in order to be able to have a visa and stay in the United States, I think I'd be able to tell you how much I love my own private practice and how much I enjoy it. But be very, very careful if you're looking for a J-1 visa job or if you're about to accept a job at some place that's promising you very high compensation. Thank you. I wasn't totally prepared for everything everyone would say, but I think we have such an interesting panel so far. And last but not least is Dr. Vito. We'll have him talk, and then we're going to start some questions. Thank you, saving the best for last. So I am a child and adolescent psychiatrist. I'm also an addiction psychiatrist, so I did two fellowships. And right now I'm doing forensic. I'm working as a forensic psychiatrist. I didn't do a forensic fellowship. And I do have a small private practice so that I have my own autonomy. So what I do want to talk about is three things. Number one, the importance of mentorship. Number two, burnout. Number three, the importance of advocacy that I would like to talk about during my journey. So during my training, I'm always complaining during training. Because every time I'm on call, I would get a teen tweaking on drugs, right? And as a resident, OK, so what do I do? So I would call the adult psychiatrist. The adult psychiatrist team said, oh, no, this should be the pediatrician. And I would call the pediatrician. No, call the addiction team. So I was going back and forth to different team treating this, and so as a resident, feeling frustrated. So I was complaining constantly. And my program director, who happened to be a very good mentor as well, he'll say, do something about it. So when I was a PGY-4, I was very fortunate. I applied and got the Gene Sparla Congressional Fellowship through the APA. So I asked my elective as a PGY-4. I had worked in Capitol Hill. And I learned about the different types of policies. I learned through working at that time with Senator Hillary Clinton from New York, a Democrat, and a Republican, Senator Gordon H. Smith, about how to make a policy or how to make a bill becomes a law. So that's a skill that I learned and had carried through. And so after that, I did Child and Adolescent Fellowship. And again, during my fellowship, every time on the call, I would get teens tweaking on drugs. At that time, party drugs was a big deal, right? And getting the runaround. There were not a lot of resources of, where do I send this patient to? Again, very, very frustrated. In my child fellowship program, it's a good program. But I felt like I need an addiction training. Like, me personally, I'm missing that. So I had asked my mentor, do I do another fellowship? Student loans, another year, what should I do? And I was asking a lot of people who actually start working. And they went back to fellowship. And they said, you know how hard it is to be making and attending money, and then going back, being a trainee, doing calls? And some people were saying, it's just another year for an addiction fellowship. And so I was torn. And knowing myself, I would be like, what if, right? Be wondering. So I did another year of addiction fellowship. Afterwards, I landed a job with Office of Mental Health, State of New York, outpatient clinic in the Bronx Psychiatrist Center. And at that time, I was told, you're going to see the patient population that are in between, they're kind of aging out, but not yet adult. So I start seeing them. And then they said, Jose, can you see also some adults? I said, sure. And then suddenly, Jose, can you cover some patients for geriatric? I said, sure, right? As an early career psychiatrist, it's very typical. And my experience, and from what I'm hearing from others, it's like, we want to prove ourselves, especially in our first job, right? During my training, it's always yes. No was never a vocabulary during my training. So it went to a point where I enjoyed teaching medical students, residents. It went to a point where, Jose, can you do some administrative work? We can't pay you more, but we'll give you a title, right? OK, well, in the beginning, that sounds very sexy, right? Sure. And then they keep putting again and again, right? The salary stays the same, right? So I have all these titles, which is fine, right? But that's where the burnout comes in, if you don't really watch yourself and unable to say no, right? And having the small private practice helped me, because it gave me a lot of autonomy. That's where I could say no, I could say yes, I could charge how much I want, because I found my niche. I'm a child, an adolescent, and an addiction psychiatrist. I also see a lot of LGBTQ during my training. The services is so limited. And so I reached out to my mentor again. It's like, I can't do this. This is too much. The things that I love, like teaching, is getting smaller and smaller, and they're giving you more administrative work. It's good that they recognize my ability for leadership, but there's no room. And if you don't watch that, that will affect you one way or another. And I spoke to my mentor. I was like, oh my God, I'm miserable. What should I do? This, this, this. And the job for forensic opened up. That was 2018. And telehealth is kind of becoming trendy and sexy, right? So you know what? There is a forensic job, and it's telehealth. It's also with the Office of Mental Health. Okay, I've never done forensic. Why would I fit in? And they said, well, first of all, Jose, you did child, and you did addiction. So you're gonna see a lot of patients in the prison system who have that comorbidity. And actually that mentor was correct, because patients in the prison system would come up to me and say, oh, Dr. Vito, you know, none of the medications work. The only medication that worked for me are Vicodin, Oxycontin. I was like, no. So as a child and adult psychiatrist, you learn to say no. So that was very helpful for me. So right now I'm in a place where I have autonomy with my private practice. And also I'm in a place where I am not pigeonholed in one thing, right? That is so important to be able to say no. And working with the Office of Mental Health, I do a lot of public policy. And that's where the advocacy comes in. And I am out of time. Thank you. All right. Thank you all so much for sharing those really snippets of your careers. I know trying to fit you into five to seven minutes is not fair. But hopefully we'll get a lot of questions, be able to expand on a lot of the really interesting topics you guys brought up. So it's a lot of similar kind of themes coming up, but a lot of like different experiences as well. And so I'm hoping that that's gonna be helpful to everyone. Go ahead, please speak into the mic when you're asking a question, otherwise it doesn't get picked up on the recording. So if you don't mind coming up, I could pass the microphone around too if people don't wanna get out of their chairs. First of all, thank you guys so much for sharing your stories. My name is Raj. I'm an addiction fellow right now. I don't really know what I wanna do after I'm done. And you guys talked about a lot of different values that are important to you, J-1 visa and VA and things that are meaningful to you, close to your heart. So kind of what did you consider when you first left training? If you don't mind speaking to that a little bit. I'll just give you a very concrete piece of advice, which is read potential contracts very carefully, very carefully, particularly with non-competes. Even though the FTC just outlawed non-competes, I think in February or March of this year, they are still in most healthcare contracts and they can be very expansive. And I've had friends and colleagues who've really gotten into trouble with non-competes that said, if you leave this practice, you cannot see any patients in a 50 mile radius for the next three years. And so read those carefully. And if you're thinking like this could be a problem, this could be impractical, speak up, say something, it probably is. And also when they say, you'll have, if you interview for a large HMO payer, like Kaiser Permanente, they'll say, you know, this is our standard contract, this is boiler template, it's non-negotiable. Everything is negotiable, especially if you have just finished a fellowship. I think the one thing I didn't realize when I came out of fellowship was how valuable and wanted and needed my skillset really is. I mean, you guys are, my husband's a pilot, so we use aviation analogies. Like in the aviation field, like you're not the flight attendant, you're not the pilot, you're an astronaut. I mean, you are the most highly trained and everybody is gonna want you, everybody. So be very picky with what you take. There's gonna be so many opportunities and read contracts carefully. Yeah, I love that. Really love the question that you pose around, how do you choose, how did you figure out? And you know, what we know from the literature, I'm a physician scientist, so I go to literature, is that most people move around after they finish their training in the first two to three years. So I think what that tells us is that people really don't necessarily know what they want and they move around until they find it. That trend is occurring more and more where people no longer stay in a position 15, 20, 25 years, they move around, okay? So I think that's just what it is. But for me, I can only speak from a place of I, I knew my values of equity, really wanting to liaise with community and being paid well and having really good work-life balance was important to me. So I knew I couldn't take a job where I was seeing 30 patients a day. I realized that there's privilege in there because I don't have to worry about day one, so I meant to say that, but I knew that wouldn't work for me. I like to get up, walk my dog, listen to hip hop. There's stuff that I like to do, right? Like to go to church. I ain't seeing nobody's 23 patients a day, right? Also, I'm a boss. I've been a leader since I was a little girl, so I also knew it wouldn't bode well for me to be in a position where somebody else is telling me what to do, right? So I think in terms of knowing all that, I knew that I wanted to stay in academia. I knew I wanted to have a lab. I knew that I wanted to write grants, all these things, right? And so that kind of led me to starting my lab at Yale. I became an associate program director, so that gave me power within the system to pick residents that I thought could be the leaders in the future, right? It was important for me to be able to influence systems. And then when I got sick of that, because I was just like, I'm over it, I knew that I wanted to just really, really focus on bringing addiction to communities. So then that's when I was like, I just need to go full-fledged into my lab, right? But those values really led me to kind of what? I cannot emphasize enough, and I'll stop talking, around reading contracts. My baby sister is a lawyer, so again, privilege. I was like, to her, read this contract, and she was like, this is total BS. So that was good, and then also, I'm like, I am addiction-trained, I have a MD-PhD, I am not taking anything less than this, period. So I don't care what the going line is for academic medicine, this is what I am starting with, and then do as if that's not gonna work for you. Literally, that's the language. So, yeah, I mean, women get paid less, and I was like, I'm not gonna get paid less. Minoritized women get paid even less, right? So really being nervous in my spirit, but going into these meetings like, this is what I have to make. I have been in school for 19 years, right? So that has to translate into something, yeah. All right, now I live a fabulous life, okay. And just to echo what you're saying in terms of figuring out what your priorities are, so I was really, I wanted to make sure that whatever I did, I continued to do teaching and supervising, that was super important. I also wanted to make sure that I had at least 30 minutes for follow-ups, that was super important to me, and again, work-life balance. One thing I would say that I didn't understand when I first started looking for jobs was I was looking at salary, okay, like this much money, oh, this one pays this much more. I didn't really take into consideration what else is being included in the package, and so looking at the VA, right, so we have our salary, but then you also have the bonus, but then you also have a pension, but then you also have loan repayment. They also contribute to your retirement account, and so if we're thinking about compensation, like not just looking at, we're giving you this number, but also like, what is the entire package and what does that include? Okay, so two things, two things, learning, going back what I've learned, two things, look into your self-reflection. Second thing, do your homework. What do I mean by that? Self-reflection, where do I wanna practice? Do I wanna practice in the city? Or do I wanna practice in the suburb? Do I wanna have kids? Is this the right setting for me, where I am right now? Or do I like to be in the suburbs, right? White picket fence houses or, you know, seeing your patients or the kids of the patients in the grocery store? Or do you wanna be in the city where you have other things to do besides work, right? So that's kind of like self-reflection, where do I wanna practice? Where do I see myself five or 10 years from now? Is this the place where I wanna be? Second thing, do your homework, meaning salary as our panelists had mentioned here, when you go for your interview, right? Ask whoever's interviewed, can I have the contact person who are currently working here can I talk to them one-on-one? So, and if you know someone in that place, call them. Are you happy where you are? Ask those questions. So do your homework. Yeah. When I was looking for a place to work, my wife was just about finishing her fellowship as well. So the most important thing was that I could find the best job available to me on a J-1 waiver in an area where she would also be able to get a job at an academic research center that where she could do Alzheimer's disease clinical trials. So there was a limitation there. But one thing I will say that would be relevant to you is that when you look for jobs, if you want an addiction psychiatry position, you're gonna find two different kinds of jobs out there. One job is gonna be an actual job that is only looking for an addiction psychiatrist. And those are almost certainly gonna be a lot better in terms of smaller contracts that I have for private practice. The places that are only looking for somebody who's board certified in addiction psychiatry, or addiction medicine, or fellowship training addiction psychiatry are gonna be significantly better than the other places that may advertise they're looking for somebody in addiction psychiatry, but then are gonna give you a lot of general psychiatry patients, or any number of other sort of patients, and only add to that addiction thing in there because they may have a couple of patients here and there who have a substance use disorder. the clinician scientists here. When you started, so sorry, my name is Namrata Wali. I'm a PGY-3 at UT Houston. I'm in research track. Research means really, you know, means a lot to me. So I would like to continue that going forward. But question is like, if I don't have an award or a grant in my, you know, final year of training, how do I ask for protective time? Or can I even get a protective time if I don't have funding to prove them that, you know, I'll be productive? Or when you got your first grant, did you do it on your own time and then got the protective time later? I'll just throw, I don't know anything about it, but my wife started out with one day of protective time. Okay, I just, I didn't know. So yes, you can get, it depends where you are gonna train at. When I, it really just depends on kind of your background, right? So I realized that there was some advantage because I was MD-PhD. I had written grants before I had money, so that's different. But I do advise a lot of my mentees now who are MD only and don't have any grants, right? So one of the things that you can do is do a 50-50 split where you're doing some clinical, the rest protected, and you can negotiate like three years until you get a K or till you get your first R01 grant. There are some institutions that'll have you, give you 70-30, 30% research. In that first year, you can apply to their internal institutional award, get another couple years there, then go for your K. So you can absolutely negotiate. You can absolutely get more than one day a week of protected time without any grants. Usually it, the max is they'll give you about three years before you have to bring in your own funding. I will say though, you definitely wanna go to a place that at least commits to protecting you 30% because there's no way that you're gonna be able to get any pilot data or do any of that if you're less than a day and a half. You just, it's not gonna work. So yes, and finding someone there, like an assistant professor to help you kind of navigate is gonna be really, really important. So Dr. Vito was saying like talk to somebody there, yeah. This also, I don't have personal experience with this, but just to mention it, my wife later found out at the place that she works that she got hired as a clinical physician with only the one day protected time but there was apparently also a separate research track that had a lower starting salary that she didn't even know about but would have taken if she had been aware of it. I am a PGY3 from Missouri. I had a couple of questions and it really doesn't need that much elaboration just to save time. First of all, Dr. Jordan, thank you for being vulnerable and talking about your mental health. That says a lot about who you are. And all the women here are phenomenal, including the men, but women are phenomenal. Okay, so my quick question, VA psychiatrists, I've seen where VA psychiatrists, besides like outpatient psychiatry, they add on more things like doing esketamine, TMS, and things like that, does that add on to your salary? So we do have esketamine, we do have TMS. I don't know specifically in our VA, but in general, kind of similarly to what people said is actually what you were saying is it didn't, most of that stuff does not add on to salary, at least at our VA. But one thing that you can do is, or we can do is like ask for time. So can I have a day a week to do this? And so some of the stuff that I do, some of it I asked for salary, but other stuff I said, cool, but I'm not gonna do it unless I get 30% of my time to be able to be devoted to this. So that's at our VA generally how it works. So more like if you wanna versatile your clinic days, I guess that's the benefit of that. Okay, my second question and my third is, what are your thoughts on locum right out of residency? Does that lead to burnout? And my third question is on more on like social media, doing speaking engagements, writing books and going part-time, thank you. I can talk about locum tenants. Locum tenants are, what I'm hearing from my, I didn't do it, but what I'm hearing from my colleagues who have done it right after training are amazing. Why is that? Because sometimes you don't know what you wanna do. Sometimes you don't wanna know, you don't know, oh, I wanna, you wanna have some flexibility with your time. I only wanna work, I only want to work four days a week. And then one day devoted to my baby, right? Or do something else or full private practice. So that's one thing with the locum tenants, kind of give you a flexibility where you can demand. Also not knowing what you wanna do right after training, you go to different settings and say, oh, I'm gonna test this. Maybe this is a place I want to work in. Maybe this is the right environment for me, right? For example, Australia, outpatient clinic, locum tenants, and you're contracted there for like six months or more, and they pay for your airfare, housing, they'll do all the paperwork for you. That's just one example. So what I've heard from my colleagues, it's a positive thing. And what I'm hearing also, it's they pay you more. And what I'll add onto there, my big financial literacy hat, another nuance that's a benefit financially is that most locums jobs are 1099 versus W-2. So in my mind, I think about the world as earner economies and owner economies. If you are a W-2 employee, you're an earner, which means you're always under ultimately the autonomy of someone else. And that can come up in insidious ways with like take on this, take on this. It can come up in more overt ways with take on more patients. Salary doesn't change. In an owner, if you're in an owner role, i.e. a 1099, you are the boss. And you don't have taxes taken out up front. So W-2, you're gonna get that 40% taken out up front. 1099, you don't get anything taken out up front. You do pay estimated taxes, but you can write off, here's a secret, almost everything. You can write off, I bought a car and I wrote it off. I can write off part of my mortgage. So 1099, you're really gonna get more bang for your buck, no pun intended, with your money because you're not paying taxes up front and there's so many ways you can write off just day-to-day things. So that's the great thing there. Oh my God, thank you. Because no, seriously, first of all, this panel's amazing. So thank you to our chair and co-chair. Because I'm learning so much from the co-panelists. Yes, money. Please, I learned this kind of late in the game because I didn't grow up in an environment there was a lot of financial literacy. So I'm learning now, but please get, if you're still in training, it's never too late, but a financial advisor, if you can, and a really good one. I actually got a recommendation from one of my colleagues in residency and it was the best decision in my life because I have learned how to make sure that I have my own, like I've worked for NYU, but then I also have my own thing, the JWC, the Jordan Wellness Collaborative, which I'm able to get 1099 income and able to write things off. But also just thinking about what you need to invest in. All these things, if we can't practice medicine anymore, that's so important. So just as important as where you train and what you do after is how do you manage your money? And that's gonna be important. So really thinking about getting someone to help you with finances. If you know how to do it, great, but if you don't, it's worth your time. And if you need somebody, whatever, I don't get paid from this, but I'm just saying, I have a really good one. Social media, then I'm gonna pass it. I love social media, but also that's because I just get to connect with people. And also it puts money in my pocket. So I will say this. I used to really love Twitter. I am no longer on there because it's a shit show and it's not what it used to be. However, during the pandemic, HBO reached out because they found me on Twitter. I had a lot of followers at the time and said, we want you to do this project where you're an expert in cannabis for this upcoming project. So anyway, at that point, I didn't have an Instagram account. They were like, what? You're not on Instagram? I didn't know because I was on Twitter. They helped me get an Instagram, sent me all this stuff. And that was in 2022. And now I'm a little bit addicted to Instagram. But the point is that that has really led to other opportunities, paid opportunities, whether it is with the New York Times, different things, cool things, the NBA, all these things. So I think, yes, figure out a lane. If you don't wanna do social media, that's fine. But also know that if you curate it right, it could be a way to actually make money. And so that's what I think the younger generation is doing so well. YouTube, all these things to make money. And you are the brand. And I'll add on real quickly. One thing, just back to the financial literacy, two of my favorite, either free or almost free resources for physicians is one you guys probably already know, the White Coat Investor. If you're not familiar with it, that's amazing. There's another somewhat newer one called LUCENS, L-U-C-E-N-S, that I'm in. It's a group only for physicians, and it focuses on financial literacy for physicians, work-life balance for physicians. I got kind of a baseline knowledge from White Coat Investor and then got some more sophisticated, physician-specific from LUCENS. And back to social media, think about what you like. So people are either kind of social media writers or social media video podcasters. I do more social media writing. If you like writing, two of the best sites to start with are Substack and Medium. You can create a blog on Substack for free. Mine's called The White Coat Warrior, which my husband says is maybe a little bit arrogant. But you can create one for free, you can put your friends on there. You can also create newsletters for free on LinkedIn. That's a great way to get your word out to a large professional audience. If you make a newsletter on LinkedIn, it automatically goes out to everybody that you're in connections with. So those are three. And then if you like podcast or video, do that as well. I tend to like more the writing because I'm not as frontward facing as Ayanna here. But just think about what kind of media you want to do. It does lead to a lot of great opportunities that you would never think of otherwise. One thing I would say about locums, there are a lot of great locums positions, but they will always pay you more than they advertise. So always ask for more. minutes or something like that, that every follow-up visit might take 10 to 15 minutes, but you'll always bill 30 minutes for those. And very frequently, they're desperate, and they're willing to accept that. Going back to the social media, yes, like our panelists have mentioned here, it's how you market yourself, how you brand yourself. For example, advocacy, I post stuff that I've written and talked about advocacy. And so people have reached out to me. Can you give a lecture, paid lecture, or a talk, not just with the medical field, but also in the business field? So what is your passion? And then how do you market yourself? How do you get that out in the world? And how do you get paid for it? And to that point, if you have a passion, but you're not strong in marketing yourself, like we went to medical school, all that stuff, there are so many credible companies that you can pay to do your social media. So like Dr. Alfie Breland Noble, who is an amazing scientist, she hires someone. It's not expensive to do all of her social media. So that's a way that she has her passion. She does her thing. But the branding, she doesn't even have to worry about. And there's somebody that she pays for $90 a month. So there's different ways that you can parlay it. And I do think that's just where the world is and will continue to go. So I think it's smart to think about that. I'm a third year resident at Morehouse. My question is how important is it for like early career things as far as when we're done with training? Because like for me, I'm thinking I want to be part time, I want to start my family. So like, is that okay? Or is it more like should you like, I don't know, set who you are as a psychiatrist early on and then be part time later? I have a friend who only works 20 hours a week and she has a fantastic life. So I think it's very doable. If you wanted to get into some sort of academic role, particularly at a more competitive place, you probably want to start that right away. But if you want to have just a nicer life and have a lot of a great work life balance, it's totally acceptable. There are a lot of good jobs, locums positions, for instance, can help you do that. As you look for something more permanent. Yeah, and I'll say you've already taken the best step and the most important, which is picking psychiatry. You know, if you are in surgery, I might say something different, but psychiatrists can have a great work life balance. I'll also say as a female, I think there's never the right time to have kids. You're a professional, you're skilled, there's always going to be something that comes up. So make that decision for when it's right for you, because something will always come up and, you know, being somebody in their mid 40s. It's more difficult as you get older to have kids, not only like fertility wise, but also just your energy level, you know, so have that be a priority and then work your professional life around it. And if you haven't read Sheryl Sandberg's Lean In, I mean, she's kind of controversial now for other reasons, but Lean In is one of the best books I've read about balancing having kids and being a really great professional executive. I don't know. I didn't consider part time, but I did know that when I wanted to have kids soon after I started as an attending and that was another reason I thought the VA worked really well for me. It was for in comparison to other people I know around in different jobs. It was a really good maternity leave package. It was 12 weeks fully paid. I was accruing vacation and sick time while I was on maternity leave, and I was able to tack on like a couple weeks even after the end of that. And so not necessarily part time versus full time, but it was definitely part of my decision making in going to the VA, and I know I'm going to stay there until I'm done having kids because that whole process was very simple and very easy. I know I'm not quite on the panel, but I'll throw on. I work full time five days a week, take some weekend calls and overnights, and I was pregnant when I started my job right out of fellowship, and because of that, wasn't there long enough to get a full maternity leave. So it was kind of a disaster, and I'd also sort of been told by HR that it would be fine, and then it wasn't, and it was like I got a call literally breastfeeding this child and crying. It was tough. It was really hard, and it was like a particularly rough day, and I got an email saying, like, when are you coming back to work because we're not paying you anymore, and I was just like, never. I hate you. How dare you? But so I had kind of sort all that out and make some decisions financially that I hadn't really planned for, and it's been difficult. I'm still five days a week. There's times where I've thought about going less or not, but I've stayed there. There's still times where I think about like four days a week or something, so it's like a balance you kind of have to strike. I will say, though, I have had colleagues and mentors who have just stepped away from the field for some period of time while they were having kids or raising young children and came back, and I don't see that it really impacted their career long-term. They may say something different, but they were well-respected, they had leadership positions, and they were able to do that. I think we're a field where there's just such a need for psychiatry. It's not like there's thousands of you running around somewhere lining up to fill the jobs. People need you, they want your expertise, and so whether you go part-time or take time off or come back, you will still be needed, your expertise is still needed, and you can adjust to being back to the field after a period of part-time or time off. So really thinking about your personal goals. When I'm struggling with the guilt around motherhood and work, and what am I gonna do, how am I gonna prioritize something? My kid is sick and my husband has a meeting for this today, and what do I have going at work? Who's gonna stay home? I'm his one mother, and there are other doctors. Our work is really important, and there are limits to us. I don't have other people just in line backing me up, but I can do some things from home. I can add patients on another day if I need to. I can make that work, but I'm in for him, so I try to balance those things and think about. Can I tell you a really quick funny story that just, I think, illustrates this issue? When I was nominated and accepted the chief of psychiatry position at Kaiser, I was 12 weeks pregnant with our first child, and I hadn't told anybody yet, and I had kind of a casual relationship with my big, big boss, so we were at this holiday party, this holiday gala, and she'd maybe had one or two drinks, and so she says to my husband, Keith, I'm so excited about Lauren. I just ask you one thing, just one thing. Just don't get her pregnant. Don't get her pregnant, because she's got so much she needs to do over the next year or so, and my husband was whispering in my ear, like, when are you going to tell her? When are you going to tell her? And so I really struggled with that. Like, oh, I've just gotten this big promotion. I'm also pregnant, but the reality is, when I did tell her, they, not to sound arrogant. We're all arrogant as doctors. They wanted me to be in that position so bad. They were like, we'll make it work. We'll have an interim. You'll come back in. So that's the whole point of Cheryl Sandler's book is like, lean in. Put your personal priorities first. Work will figure itself out around that, because you've proven yourself as a great leader. And then one other thing to think about, I guess two other things, another plug for the VA, non-birthing partners also get the 12 weeks, which is awesome, but also something to consider or ask about is like, in those situations, if your child is sick, or if like, how do you take off? Like, I know where I did residency, you had to use one of your like 10 vacation days to take off, versus where I'm at now, we have like so much sick, I don't even know how much sick time we get, because I have like weeks banked, but anytime my kid is sick, anytime they have a doctor's appointment, I can just use sick time, I'm not using vacation time. So that is something to consider and looking at places is like, what happens and how can people accommodate? And it's all in the fine print of the contract. So again, back to the contract, read every sentence. And that's the beauty about private practice, right? You set your time, and you also set your price. So that's the flexibility and the autonomy of having a private practice. I just want to add one sentence, I know that's not on the panel, but I am very new, I just got my job a year ago after graduating. I reviewed my contract, I did it through a lawyer, and the lawyer gave me some comments, and I agree with most of them. And the other side also gave me the talk that this is standard, we can't change it, blah, blah, blah. So I end up taking the contract, and I like most of the stuff on it, but then there are things that I learned later that, oh, I could have done this better in this way and that way. I did the big stuff like with the restrictive covenant and things like that, I was okay with the small things. Some language turns out it could be a little bit better, and it was pointed out by the lawyer, so you should always listen to them when they say something. So, and I want to just say this one sentence here, don't get too freaked out. You will change your position probably two or three years later, so if the first one is not perfect, don't worry, that was your practice one. Learn everything you can, and then know that there will be always other places. You come to AAAP, you're connected, you talk to all these wonderful people. One other advice is that always save people's number, first name, last name, and their email, because you don't know when you need them, because one of my attending from way back when in residency is the one that got me the job today. So you want to keep those connection, and then your first job is your practice one, and I'm sure you'll all find wonderful places to go after that too, so. And beware of the golden handcuffs. Do you guys know what the golden handcuffs is? Okay, I'm gonna tell you. There are some places, some HMOs, Kaiser is one of them, where if you're coming straight out of fellowship, they'll say, we will give you $200,000 upfront as loan repayment, but the fine print of that is if you leave, in Kaiser, if you leave seven years prior, you owe 50% of that back. If you leave five years or less prior, you owe 100% of that back. So I saw, and this is fairly common in large HMOs, I saw really unfortunate situations where people stayed at that job a lot longer than they wanted because they had taken that money upfront, and then they couldn't afford to give it back. I saw situations where people also got terminated, and then they still had to give the money back. So beware of the golden handcuffs. Make sure that's taken out. Those are negotiable, too. Would you comment about non-compete clauses? Oh, yeah, yeah. So non-compete clauses, we talked a little earlier about this, so the FTC has outlawed non-compete clauses, but they're still in most contracts. I think most companies are ignoring that. They've been in every single contract that I've looked at, and I have negotiated them out of every single contract. They're usually very overly restrictive. I mean, and there's two different parts. Ayanna was talking about the restrictive part, which says you can't practice within a 50-mile radius for the next three years doing this. But there's also what's called non-solicitation components of some contracts would say, if you leave our organization, you can't take or treat any of the patients who you did our organization. It's huge because a lot of folks like to start in a large organization right outside of a fellowship to kind of get their feet wet and their belt into the ground. Once they get tired of being an earner versus an owner, they'll go into private practice. But if you sign a contract that has non-solicitation in it, you technically can't take any of those patient relationships that you've built over years and years and years. So the non-competes are in every contract, unfortunately, but you have the power to get them taken out. I always get them taken out. Read for non-solicitation as well, because those are in most contracts, and they're a little bit trickier to get taken out. I will say they're hard to enforce. That's just the other thing. In the kind of vein of compensation, which was a really good point that you mentioned around salary's important, but not everything in terms of what are the other ways, matching retirement, vacation, et cetera, is things like daycare costs and dry cleaning and transportation, parking. There's so much that you can consider. You can look up sample contracts that have these things in it that I wouldn't have necessarily thought to think about, except for we took a negotiation class at Yale, and so these were some of the things that were added to the contract that people would cover. So that's another thing to think about. And then when you are, now this is in academia, when I moved from one place to the next, so you guys who, if you stay in academia, may move from one place to the next, think about negotiating moving costs, of course, but also down payment for homes. So that was a big, big thing. And so I've had mentees who have bought homes in New York City because they were able to negotiate down payments, because it's expensive to live, and that's how they're able to get their apartments, condos, whatever. So there's many things to consider beyond just your salary. Obviously that's big, but you wanna think about some of those more fluid points. So there's about 15 minutes left. I think that's probably enough time for like one, maybe two questions. So keep them coming. Hi, I'm Maddie. I'm a medical student from Vermont. I was just curious if y'all could talk about, like people who have done private practice could talk about how you set that up, what that looks like for you. Awesome. So talky. I will say I think the most important thing to consider going into private practice is which EMR you choose. If you're in private practice, you will live or die by your EMR. And like everything else in life, you get what you pay for. There are some really cheap ones out there that are just quite frankly trash. And then there's some ones that are a little bit more expensive, but you really get a good bang for your buck. So when I was in practice, I used Tebra, formerly known as Cario. It's phenomenal. It's priced kind of midpoint, but it's got a great patient portal. It's got scheduling. I actually, unlike most people in private practice, took a variety of insurances as well. But I had a biller who would do all that. I would not recommend trying to credential yourself and do the billing yourself. But you can hire a biller for fairly cheap who will credential you with five or six of the large ones that pay the most. Medicare tends to reimburse pretty high. So anyway, look at, I'm trying to be succinct like Jose. EMR is very important. The second point is you don't have to necessarily be cash only or pay to play. You can do insurance. You just need a credential and a biller. And I also think, yeah, echoing Jose and Robert, it offers so much autonomy. You set your schedule. You set your reimbursement. You can even, people don't think you can set your reimbursement with insurance, but you can. I had some success talking to Tricare and Anthem directly and saying, this is your general reimbursement for a general psychiatrist. I'm an addiction psychiatrist. It should be higher. And they'll do it. They'll change it. But EMR, I mean, I cannot emphasize enough. There are some terrible ones out there. There are some wonderful ones. I think Tebra and Kipu are some of the best. Steer clear of ICA notes. I could go on and on about that. I actually have a whole article about choosing an EMR, so look it up on there. Two other things that I think are important is if you're opening a private practice and you also have another job, make sure that you know what your other, like, it's a little bit geographically dependent and employer dependent, but some employers will take a portion of your private practice money. So make sure that you know that. In New York, it's like a lot of money. So the VA doesn't take any of your money. And the other thing, just to echo, is flexibility, right? And so having a kid, I only see private practice people after my kid goes to bed. So my appointments are at 8 p.m., 8.30 p.m., 9 p.m., which is actually really helpful for a lot of people who are looking for not having to take time off of work to go to psychiatry appointments. And so that's another benefit. When I was in fellowship, some of the attendings were just asking me if I was interested in working at a rehab or something like that or seeing some patients on the side because those patients either were unable to pay their very, very high cash rates for private practice or that the rehab was not able to pay what they were asking, but it was still a very good compensation rate, so they offered it to me. You do have to have an EMR or at least some sort of program where you're able to prescribe medications. I use MD Toolbox. I think it's pretty good. And you do have to set up a way to take payment as well. I use Square for that, which is the same as a lot of restaurants, which is annoying because Square, if you ever go to a restaurant and you pay with Square, you sometimes get emails from them. So unfortunately, when you send the email payment things to patients, sometimes they've already blocked Square because they ended up getting all these unsolicited emails from restaurants. But if you have those two things set up, it's actually pretty easy to do. Just make sure you have a decent enough cash rate if you ask too low. And I think I was asking a little bit too low in the beginning. I was getting too many patients too quickly. So I bumped that up and now it's pretty reasonable. Okay, really quickly, the other thing about private practice that I'll say is if you're kind of nervous and you don't want to, not exactly sure, you can just, what Dr. Rito was talking about related to mentorship. So I started in private practice when I was still in fellowship, my addiction fellowship at Yale under one of my mentors who had a really robust private practice. And he said, Ayanna, I just need help. And so I was able to figure out the EMR, understand who I wanted to see, my rate, and all that kind of under his tutelage and get my folks. So that's another way that you can kind of do it is really feeling like, okay, how can I work with my mentor for the first one or two years until I kind of get my reputation in order and then kind of jump ship? So there's many different ways to do it. But I, again, which is so nice about psychiatry, what you're finding is you can do many different things. Like you don't have to, I mean, you can do private practice alone, but you can do academia and private practice and consulting and medical leadership. Like there's many different things you can do. So don't feel like you have to just do one thing and stick to it. That's fine. But there are other multiple streams of income, which is really nice. There's also a company called Silver Lease. Silver Lease is amazing. I wish I had stock in there. Silver Lease is amazing. I don't own any stock in their company, although I wish I did. But they basically will set up everything for you for a private practice. They'll do your website, really professional looking. They'll do your social media marketing for it. They'll set up the EMR. And they, Silver Leaf, I think, uses IntakeQ, which I really like as well. So they're basically like, you can, the fees are pretty reasonable. You can pay them a set amount and say like, do everything to set up my private practice, and boom, they'll set up your website, they'll set up your social media. They also even have templates for, that you can buy for your notes. They have like a prior authorization appeal template. They have an HPI for psychiatry. They have a controlled substance agreement template. They have an ROI template, and each one's like $5 you can buy, versus like trying to reinvent the wheel. So I've used them, I use them in private practice as well. They were great. They're also owned by, I think, a nurse practitioner, so they're very healthcare friendly. But great rates, they'll do everything for you if you want like a hands-off approach. I wanna add, in addition, what I tell my trainee, this always comes up, how do you set up a private practice? I tell them, know your self-worth. What I mean by that, I don't accept insurance, even from the very beginning. And we, as medical profession, we have a hard time asking and charging, right? And so in the beginning, I was charging this amount, and my mentor is like, no, no, no, Jose. You gotta bump it up, right? So I have a hard time doing that from the very beginning. So what I tell my trainee, know your self-worth. So when you see patient, this is my fee. Now it's up to you, do you accept sliding scale or not? So this is something that you want to examine yourself. I have trainees who have just graduated and charging much more money. So what's your comfort level? And I think that would be a good start. Can you tell them, I bet they're all wondering this, but none of them wanna ask it, what's a reasonable range to charge for private practice? I bet they're wondering it, but nobody's gonna ask it. Depending on where you are, right, depending your location, I think it's important to do your homework. Who are you competing with, right? And start from there and inquire. The initial evaluation and follow-up. Now being a child and adolescent psychiatrist and also an addiction psychiatrist, I found my niche. So there's not a lot of people that does that. Now it doesn't mean I only see child and adolescent, I also see adult as well with addiction. So you can make or you can charge your comfort level, right, depending on where you are, your location, and your patients who can afford it. Yeah, I mean, some numbers. I mean, listen, again, really know your worth, your own values, what drives you. You know, some people have a model of like Peter Pan, charging the rich, giving to the poor, being able to accept a 20% sliding scale or pay what you can. For me, there's many different ways you can do it. You can consult, like if there's, in Harlem, there's people who can't afford at all and then you can consult and like one day a week, two times a month to provide medical care for free. If you're doing private practice, it just really depends on your values. In New York City, you can go from $400 an hour all the way up to packaging 850, sometimes $1,000. So that's not uncommon. And it can get higher and higher depending on if you have like specialty child and adolescent or child and adolescent forensic, you know, all different types. So the numbers are kind of all over the place. I know I was shocked, quite frankly, when I was looking for my own niece to get in with a child and adolescent psychiatrist that specializes in ADHD. I was like, you're charging me how much money? And I'm a physician. So again, it can get very pricey, but you know, again, it's kind of knowing the market and what you feel comfortable with, but it can, it's a large range. I mean, some people charge $200 an hour, but again, you can go 450, 850, 750, 1200. Like I'm not exaggerating. So those are numbers that people charge. Yeah, in the DMV area, we say DMV for DC, Maryland, Virginia. In the DMV area, it starts around, the lowest end I've seen is like 200. The highest is about 1,000. The average, and I'm talking about hourly cash rates, the average is between 600 and 800 an hour. So high ROI, return on investment is another business term. So we just have four minutes left. I don't think there's time for like a full panel answer to the question, but I want to thank everyone for the questions. I really want to thank our panelists. Guys, honestly, really awesome. I learned a lot. I felt like this was really useful for me. And I hope everyone here got something out of this and just really highlights the breadth of the field and like how much you can do. And just round of applause for our really awesome panelists. Thank you for your honesty. Thanks for being vulnerable. Thanks for, you know, giving all this personal information. It is so helpful. So I really hope it helps all of you.

addiction psychiatry

career paths

work-life balance

mentorship

financial literacy

contract negotiation

non-compete clauses

personal values

VA benefits

private practice

locum tenens

professional autonomy

career planning

Dr. Denae Duracko

Dr. Chun Tong

Dr. Lauren Grawert

private equity

culturally informed care

VA employment

employment contracts