Your new concierge psychiatric practice – an introduction

September 28, 2010

Be patient with me here. This is really important.  If you don’t get this stuff right all the rest is useless. Well, maybe not useless but certainly a lot less fun.

In The Teachings of Don Juan, Don Juan Matus told Carlos Castaneda,

“Look at every path closely and deliberately. Try it as many times as you think necessary. Then ask yourself, and yourself alone, one question – Does this path have a heart? If it does, the path is good; if it doesn’t, it is of no use. Both paths lead nowhere; but one has a heart, the other doesn’t. One makes for a joyful journey; as long as you follow it, you are one with it. The other will make you curse your life. One makes you strong; the other weakens you.”

Please don’t take my quoting Don Juan’s brand of wisdom as a recommendation to go out and start chewing peyote buttons! You’ll surely stray from psychiatry’s careful path! Truth comes at us from all directions. The challenge is to notice it and to sort it out from all the other useless chattering. In this passage he speaks a fundamental truth. Please allow me to use it in the following way – take care with the choices you make in life, the paths you follow – where you live, how you make a living, and with whom you partner.

A bad partner will make your life miserable. Certainly many life lessons will be learned along the way with a bad partner, perhaps especially with a bad partner, but my very strong plea is to be extremely thoughtful about whom you choose. If you are already in a life partnership, carefully weigh its pros and cons. Unless you can say unequivocally that the person in your life wants something close to what you want from this life – get out. Do whatever it takes as soon as possible to extricate yourself from this arrangement. I am certain that you will do better on your own than you will ever be able to do while mired in a destructive partnership. For our purposes a partnership that is anything other than unabashedly, unequivocally productive and growth promoting for you both is deemed destructive. Rid yourself of any destructive element in your life. I’m sure you know what I’m talking about here. You are very good at tolerating this person or that bad habit being a part of your life – but WAKE UP! Move on. Stop the madness.

How to know you are partnered with the wrong person.

There is no joy in being in their presence. Their presence in your life takes more away than it adds. I want your partner to be a steady inspiration for you. A constant spur for growth. There is nothing easy in that. But the work of growth and development is something entirely different from the soul murder of living with the wrong person. A mutual coexistence may be attained with anyone but that offers you nothing, yields no fruit. Ditch that one, live on your own until you are fortunate enough to find the life partner deserving the name. But in the context of mutuality, mutual growth and development, real joy happens on a regular basis. Surely frustration and troubles occur but here joy in a vital life together is a regular experience.

Really any compromise on this point is dangerous. Be very careful, thoughtful and deliberate. Ruthless.

Where to live?

Staying right where you are now is absolutely the easiest choice. If it’s right for you. Let’s say you are a psychiatry resident in your final training year. You know people in your community; you have met practicing psychiatrists as you have progressed through your education; you may even have several patients that can become the nucleus of your new practice.  And you have a tremendous advantage: by virtue of being a part of your psychiatry department you have access to possible part-time jobs in the community that would provide the financial bedrock of your new, independent life. But all this is for naught if you live in a place that kills your soul. How does one know?

Don Juan Matus taught Carlos the concept of The Spirit of a Place. Pay very close attention: every spot on our planet is unique. From a purely monetary point of view your practice home needs to have lots and lots of people nearby. How many? Lots. Most people are very primitively organized. Vast numbers of us are ruled by superstition and odd belief systems. But there is a minority amenable to making use of your services. My particular bias – there is nothing evidence-based here beyond what I have seen first hand – is that the more rural a place is, the more prevalent is the primitive organization. I would recommend on this basis alone living in the largest city that feels right for you. But I digress – pay very close attention to the spirit of your place.

How to sense the spirit of a place.

This may well sound crazy to you. Since you are a psychiatrist you have been trained to think hyper-intellectually. At least that goes for me! In order to perceive a place’s spirit you must feel your way. We do this all the time. We call it intuition. It really is a mode of perception. Does this place feel right? How many places have you sampled? Travel! Feel the world! You will know it when you feel it, but taste different places as early and as often as possible.  Compare the feel of them. I promise you that you will find it if you persist.

If you are certain that the home of your psychiatric training is not the right place for you to live – move. The advantages of living in the right place will so far out weigh the disadvantages of having to start completely from scratch that there is really no choice from my point of view.  This is an easy position for me – I’ve tried it both ways. The right place is a joy. Living in the wrong place feels deadening and mirthless. Move!

Should you become clear that you will be moving at the end of your training, start now making contact with clinicians in your chosen city. Use the recommendations on networking that will be included in our soon to be released eBook in your intended practice home. It is never too early to market. Marketing, networking, getting to know other people in your community – whatever term you use for this activity – is crucial. It is the life blood of your practice. It should become something you think about every day. The time to market is NOW. Market early and often.

The point is this – if you are reading this and you are a fourth year psychiatric resident planning to start your practice in a city different from your training home, it is a very good idea for you to plan to establish a presence in that next place NOW. Begin now designing a business card. Build your website and blog NOW. Write – NOW! You will be glad you did when it comes time to see patients in your office. We’ll get into the details of all this later on but you should be thinking down the road right now.

But what kind of psychiatrist are you on the way of becoming?

Do you have a sense of exactly the sort of psychiatrist you want to be? As I started out in practice I was certain. I learned psychiatry in a residential treatment setting that was a free-standing psychiatric hospital. This was back in the days when inpatient psychiatry was a profitable and, at least as far as I could tell, an honorable way of making a good living. I was offered a job at the old alma mater but my character “defects” prevented me from taking the easy way. Actually the fact that people rub me the wrong way most of the time and that I am touchy as hell has determined the style of business life I have led – until this marriage I have been strictly solo as far as business goes.

I did work as a staff psychiatrist in a hospital for a couple of years right out of residency. It paid the bills. After my move to Chicago I was fortunate to be hired on as a psychiatrist at Cook County Jail. An amazing experience (Thanks, David!).

But by the time I finished my residency I was committed to becoming a psychoanalyst so I started psychoanalytic training right after residency.  I clearly imagined myself as a psychoanalyst. Back then this was a natural step. Most psychiatric departments were headed by psychoanalysts, believe it or not. The movement away from psychoanalysis toward biological psychiatry had already begun early in my career but my point here is that psychoanalytic training was a natural choice then for a young professional interested in being the best clinician they could be. There are many possible “flavors” of psychiatrist now a days. From the point of view of this book and my consulting practice the most important thing is to have a clear vision of what sort of clinician you want to be, therefore the type of practice you want to build.  One can imagine that this is what your experience so far has taught you – what brand of clinician have you become? Naturally this will not be written in stone. My ideal image of my professional self has changed. I now think of myself as an excellent general psychiatrist, capable of practicing modern psychopharmacotherapy as well as a psychotherapy that morphs depending upon the needs of the patient. I no longer fancy myself the pipe-smoking analyst I once did.

Back in those early days I needed the fantasy of becoming just like the more senior analysts I knew and especially the analytic heroes of the day. The dark-suited, reserved, hyperintellectual, pipe smoking super analyst was in me – I just had to keep working real hard to cultivate that persona. I do think it was a great idea, but it ultimately wasn’t right for me. But it helped me developmentally tremendously. How?

Looking back on the earlier version of myself I can clearly see how unformed I was as an individual. I was put together well enough to jump through all the hoops but I really didn’t have a good sense of myself as my own person. Life has taught me many important lessons. I still value my psychoanalytic education and in some ways still look on that path with respect. But along the way I turned away from the path I had imagined back 20 plus years ago. Having that image and playing with becoming it functioned as a perfect scaffolding for my growth and ongoing adult development. It is, on that basis among others, still precious to me.

That was me. How about you? How well formed are you as a person? Are you clear enough about yourself to have an idea of what sort of psychiatrist you are becoming? I imagine so. I was remarkably lacking in basic self skills that many people have firmly installed by this stage of the game. I have much confidence in you – if I was able to accomplish what I did given my capacity you will do better faster.

So here we go – Assuming you have a good life partner, you are living in the right place, and that you know what sort of psychiatric practice you plan to build, you are now ready to roll up your sleeves and get on with this most excellent adventure.

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