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ENTERING
PRIVATE PRACTICE
A Handbook for Psychiatrists
This page intentionally left blank
ENTERING
PRIVATE PRACTICE
A Handbook for Psychiatrists
Edited by
Jeremy A. Lazarus, M.D.
Washington, DC
London, England
Note: Books published by American Psychiatric Publishing, Inc., represent the
views and opinions of the individual authors and do not necessarily represent the
policies and opinions of APPI or the American Psychiatric Association.
Copyright © 2005 American Psychiatric Publishing, Inc.

ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper

09 08 07 06 05 5 4 3 2 1
First Edition
Typeset in Janson Text and Bailey Sans ITC.
American Psychiatric Publishing, Inc.

1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data

Entering private practice : a handbook for psychiatrists / [edited] by Jeremy A.
Lazarus.-- 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-141-2 (pbk. : alk. paper)
1. Psychiatry--Practice--United States.
[DNLM: 1. Private Practice--organization & administration. 2. Psychiatry--
methods. 3. Practice Management. WM 30 E61 2005] I. Lazarus, Jeremy A.
RC465.6.E55 2005
616.89'0068--dc22
2005008200
British Library Cataloguing in Publication Data

A CIP record is available from the British Library.
CONTENTS
CONTRIBUTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
1 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 FINDING THE BEST POSITION FOR YOUR MEDICAL CAREER—

AND YOUR PEACE OF MIND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Roger G. Bonds, M.B.A., F.M.S.D., C.M.S.R.
APPENDIX 2-A: Planning Your Career Search. . . . . . . . . . . . . . . . . . . . . 25
3 THE MANY FACES OF PRIVATE PRACTICE . . . . . . . . . . . . . . . . . . . . . .27

4 THE PSYCHIATRIC OFFICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Jonathan M. Kersun, M.D.
Edward K. Silberman, M.D.
5 MARKETING PRIVATE PRACTICE PSYCHIATRY

Ten Internal and Ten External Practice Tips . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Marcia L. Brauchler, M.P.H., CPHQ, CPC
APPENDIX 5-A: Sample Patient Survey Questionnaire. . . . . . . . . . . . 65
APPENDIX 5-B: Suggested Outline for a Patient Brochure. . . . . . . . . 69
APPENDIX 5-C: Sample Referring Physician Questionnaire . . . . . . .71
APPENDIX 5-D: Sample Press Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
APPENDIX 5-E: Sample Pitch to the Media for a Story in Which
You Could Be Used as an Expert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6 OBTAINING REIMBURSEMENT FOR OUTPATIENT SERVICES

FROM MANAGED AND UNMANAGED INSURANCE
Principles and Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77
Michael I. Bennett, M.D.
APPENDIX 6-A: HCFA 1500 Form, Common Data Requirements. . . 95
APPENDIX 6-B: HCFA 1500 Form, Medicare Data Requirements . . . 97
APPENDIX 6-C: Sample Information Sheet: Understanding
Your Insurance Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
APPENDIX 6-D: Sample Notice to Patients Regarding Cost of
Ancillary Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
7 COMPUTER RESOURCES FOR THE PRIVATE PRACTICE . . . . . . .103

John Luo, M.D.
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124
8 HOW TO COLLABORATE WITH PRIMARY CARE PHYSICIANS

TO ACHIEVE BETTER OUTCOMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Steven Cole, M.D.
9 TOP TEN LEGAL AND RISK MANAGEMENT AREAS OF

CONCERN FOR PSYCHIATRISTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
Anne Marie “Nancy” Wheeler, J.D.
APPENDIX 9-A: Model Collaborative Treatment
Relationship Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .161
10 ETHICS IN PRIVATE PRACTICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177
CONTRIBUTORS
Michael I. Bennett, M.D.
Supervisory Staff, Massachusetts Mental Health Center, and Medical
Director, Mental Health Case Management, Chestnut Hill, Massachusetts

Chief Executive Officer, American Academy of Medical Management,
Roswell, Georgia
Marcia L. Brauchler, M.P.H., CPHQ, CPC

President, Physicians’ Ally, Inc., Highlands Ranch, Colorado
Steven Cole, M.D.

Professor of Clinical Psychiatry and Head, Division of Medical and Geri-
atric Psychiatry, S.U.N.Y. Stony Brook Health Sciences Center, Stony
Brook, New York

Private Practice, Swarthmore, Pennsylvania

Clinical Professor of Psychiatry, University of Colorado Health Sciences
Center, Denver, Colorado
John Luo, M.D.

Assistant Clinical Professor of Psychiatry, UCLA Neuropsychiatric Insti-
tute and Hospital, Los Angeles, California

Vice-Chair for Adult Services (medical school appointment pending),
Department of Psychiatry, Tufts-New England Medical Center, Boston,
Massachusetts
Anne Marie “Nancy” Wheeler, J.D.

Attorney in Private Practice; Coordinator, American Psychiatric Associa-
tion Legal Consultation Plan; Affiliate Faculty, Loyola College in Mary-
land, Graduate Pastoral Counseling Program, Columbia, Maryland
vii
1 INTRODUCTION
F or the psychiatrist who is recently trained or who is planning a career

change, the prospect of entering private practice is at the same time very
exciting and fraught with questions and concerns. This book was conceived
after the editor’s many years of organizing seminars for psychiatric resi-
dents who were trying to make career decisions. Although some residencies
offer limited guidance or mentoring on entering private practice, there has
been no comprehensive curricular approach—and, indeed, there is already
too much to learn about the art and science of psychiatry to spend signifi-
cant educational time in this area. What most psychiatrists want is practical
advice from those who have experience and are experts in specialized areas.
Although no one book can contain all of the information that will help in
setting out on a career in private practice, this book will give the reader a
substantial head start. It will also provide help in avoiding the pitfalls that
have been experienced by many. For this purpose, I sought to bring to-
gether experts in marketing, job searching, buying insurance, communi-
cating with primary care physicians, setting up a private office, using
technology in the office, and dealing with legal and ethical issues. It is also
crucial for the reader to ask the advice of trusted friends, colleagues, teach-
ers, and family in arriving at the best practice situation. Don’t assume you
know how things will go in a particular practice setting without doing your
homework. If you do your homework and follow good advice, you will get
the most out of your practice.
The first critical question to ask oneself is: Does private practice offer
me the type of work and living situation that will make my professional and
personal life fulfilling? From over 30 years’ experience in private practice,
1
2 ❚ ENTERING PRIVATE PRACTICE
and having talked with psychiatrists around the country, I think it’s fair to
say that there is no other place where one can experience the unencum-
bered joy of treating the individual patient over a short time or over de-
cades. There is no other situation where you can be free to practice in the
style and with the theoretical and scientific background that are most con-
sistent with your training. There is no other way that you can be the sole
master of your professional fate and accept both the responsibilities and the
risks. But to reflect more systematically on this question, I offer the follow-
ing discussion of advantages and disadvantages of private practice and then
briefly discuss other activities you can be involved in to enrich your profes-
sional and personal life.
❚ ADVANTAGES OF THE PRIVATE PRACTICE OF

PSYCHIATRY
Private practice offers many advantages:
• Autonomy
• Choice of clinical work
• Choice of range of clinical work
• Choice of area in which to live and work
• Range of income
• Flexibility
Let me discuss each of these in more detail.
Autonomy
Being one’s own boss and having the freedom to make all of one’s choices
as a professional are deeply held values for many, and they are most fully
expressed in private practice. You can choose whom to serve, where to serve
them, how much to work, where to work, with whom to work, and how
much income to seek. In addition, there is the emotional and psychological
sense of freedom that comes with running and owning a professional prac-
tice and business and making decisions according to your own wishes.
Choice of Clinical Work

Although there may be limitations on the full expression of your choice of
the type of patient to see when starting out in practice, over the course of
time you can aim to work with the types of patients whom you feel you
Introduction ❚ 3
serve best and who are of the most interest to you professionally. You can
determine whether you prefer primarily psychotherapy, psychopharmacol-
ogy, psychotherapy plus psychopharmacology, individual or couples ther-
apy, group therapy, or other modalities of therapy/treatment in which you
are most expert.
Choice of Range of Clinical Work

You can choose a fee-for-service or third-party reimbursement practice or
a combination. Many psychiatrists mix treatment of full-paying patients
with insurance, managed care, or preferred provider organization (PPO)
practices. Through managed care or PPO practices, you may be able to re-
quest patients with a particular diagnosis or with problems that you have a
particular expertise in treating.
You can also choose whether you want to work by yourself or in collab-
oration with other psychiatrists, physicians, or mental health professionals.
I will cover this aspect in more detail in the chapter on types of private
practice (Chapter 3 of this volume), but it is important to recognize the
wide variety of clinical practice opportunities available.
Choice of Area in Which to Live and Work

Although it may seem obvious, if you are entering a private practice, you
have the ability to choose the state you wish to live in, an urban or rural
practice, whether you want to live near to or farther from your work, and
other lifestyle options that will make your personal life a gratifying one.
Some psychiatrists choose to work in an urban setting and live in the suburbs
or in a rural area; others do the opposite. Some psychiatrists work in multi-
ple settings, dividing their time between an urban practice and a commut-
ing rural or suburban practice. Ultimately, the choice of where to practice
and where to live will be determined by your interests both professionally
and personally.
Range of Income
The range of income that one can expect in private practice is dependent
on a host of variables. These include whether you draw from a full-fee-pay-
ing population or receive reimbursement from insurance or other third-
party payers, the number of hours you work per week, and the number of
patients you see per hour. With some upper limit on the number of hours
you work per week, the principal way you can reasonably expect to increase
your income is by doing types of work that may pay more, such as forensic,
consultation, or other administrative work. It is also possible to increase in-

come by using a physician extender model, employing other mental health
professionals.
Because most psychiatrists do virtually no procedures and have no other
in-office means of increasing income, we are limited to our cognitive abil-
ities and time. Nevertheless, a decent income can be achieved with a rea-
sonable work week. Although there are no guarantees, finding the right
practice niche will usually include an assessment of future income. If you
happen to be purchasing another psychiatrist’s practice, additional assess-
ment with good consultants can help you estimate your potential income.
Income ranges in various parts of the country are available through both
the American Psychiatric Association (APA) and the American Medical As-
sociation (AMA). APA and AMA are also good resources for other practice
management information. They can be accessed on the Web at http://
www.psych.org for APA and http://www.ama-assn.org for AMA. There is
also valid evidence that practicing in a group may provide a higher level of
income than practicing solo.
Flexibility
As your own boss, you can decide on which days, weeks, hours, and places
to work. You can work in an office part- or full-time, work in another set-
ting part-time, volunteer at a university or clinic, volunteer for psychiatric
society or medical society meetings, and take part in other activities either
professionally or personally, during the work day or in the evenings. The
bottom line is that your hours are yours to decide on and you can mix your
professional activities with your personal activities as you wish. You have
the maximum ability to plan your day and your week in a private practice
setting.
Of course, in a private practice you may have increased responsibilities
to patients that you may not be able to share with others. However, even in
private practice, you should be able to arrange call sharing (if you wish)
with other psychiatrists for evenings, weekends, or vacations. In my own
practice, I have had a group of five to seven psychiatrists take evening and
weekend calls without problems over the past 30 years.
❚ DISADVANTAGES OF PSYCHIATRIC
PRIVATE PRACTICE
Having gone over some of the advantages of private practice, let’s now look
at some of the potential disadvantages:
Introduction ❚ 5
• Limitations on professional work

• Full responsibility for patients and business
• Uncertainty of income and benefits
• Less frequent interactions with colleagues
Let’s take a look at each of these.
Limitations on Professional Work

Let’s face it: If you want to do full-time teaching, research, administration,
supervision, public sector work, writing, or other scholarly work, then pri-
vate practice is probably not for you. Although there are numerous oppor-
tunities to do all of these part-time, if your heart is in one of them, you
probably won’t be fulfilled in private practice. On the other hand, one of
the advantages of private practice is that while engaged in it you can still do
these other things part-time. I myself have been able to continue an active
private practice, teach residents, volunteer for a free clinic, write, and be ac-
tively involved in organized psychiatry and medicine. Of course, I haven’t
been able to do all of these things all of the time or with full commitment
to each, but you can choose your hours and the timing of your involvement.
In addition, it may be possible in another treatment setting, such as an
academic center or a public or other clinic, to treat a specific type of patient
that you might not be able to see in a private practice. Being able to draw
from a larger volume of patients in these settings may be an advantage over
private practice.
Only you can decide what will give you the most professional satisfac-
tion—and if patient care as a primary goal is not your desire, then private
practice is probably not the best way to go with your career.
Full Responsibility for Patients and Business

Although you can always find other psychiatrists to share coverage for you,
in general a private practice means that you respond to patient calls either
personally or through office staff. You take full responsibility for your pa-
tients, and you either prosper or perish based on your professional and in-
terpersonal abilities. Also, you take full responsibility for running the
business aspects of your practice. Although you can get appropriate profes-
sionals and staff to help you, ultimately you are the captain of your ship and
it sails or sinks under your command. In other settings, you may be able to
rely on others to assist with the patient care aspects of practice as well as
the business activities. You may be involved in an advisory capacity, but
the business aspects are often out of your hands. This may or may not be
appealing to you. Some of us really enjoy the business parts of practice, and
others of us want to keep a good distance from those activities.
Uncertainty of Income and Benefits

No matter what you project or what you are told, you can never be abso-
lutely assured of a particular income in a private practice. Unlike a salaried
position, where you can count on a certain monthly amount accompanied
by various benefits, a private practice may not have a reliable cash flow that
you can count on from month to month. This is especially true at the start,
when you are still building up your practice and it is unlikely that your
hours will be entirely taken. The benefits that are available to you in a sal-
aried position may also be better than what you can arrange for in a private
practice. Large institutions or clinics can often negotiate for better and less
costly health benefits and may also be able to provide you retirement, dis-
ability, and other insurance benefits either at better rates or as part of an
overall compensation package. On the other hand, as a private practitioner,
you may wish to have a broader array of benefits available—at your choice
rather than your employer’s.
Less Frequent Interactions With Colleagues

Depending on the type of private practice you envision, you may find your-
self less connected with others in the practice setting than you were either
in your residency or in an employed role. This can always be offset by prac-
tice arrangements, which I discuss in Chapter 3 of this volume, but it is
fairly clear that if you are a solo practitioner, you may find yourself alone
during a good part of your professional day. If you thrive on teamwork, col-
laboration in patient care, and time to have stimulating intellectual discus-
sions about the science and art of psychiatry, then—unless you can find the
right part-time mix to provide those opportunities—you may find private
practice unfulfilling. If those types of experiences are important to you, but
you don’t wish them to occupy you full-time, then you can mix those activ-
ities with private practice.
❚ OTHER CONSIDERATIONS
Now that we have taken a look at some of the advantages and disadvantages
of private practice, let’s look at some of the possibilities in your professional
and personal life that will enrich your private practice experience.
Although seeing patients is the primary focus of a private practice, this
doesn’t preclude your involvement in a wide variety of professional oppor-
Introduction ❚ 7
tunities. You can volunteer to supervise or teach residents or medical stu-

dents and be a part of the clinical faculty at a university medical center. You
can volunteer to do pro bono work in clinics for the uninsured or in other
community clinics. Some psychiatrists volunteer to be on the state board of
medical examiners or provide services to the impaired-physician program.
There are opportunities to be on committees on hospital medical staffs or
in your APA district branch. You can also join your county and state medi-
cal society and volunteer for committees there. All of these provide you
with opportunities to meet other psychiatrists and physicians, stay active
professionally in your community, and offer possible leadership advance-
ment opportunities. Don’t expect to start at the top of the food chain in any
of these settings, but time and good work will eventually pay off with even
more gratifying experiences. These volunteer roles may also improve your
referrals and stature in the community as well as being gratifying on their
own. Contact your APA district branch and the state or country medical so-
ciety, as well as the AMA, to find out what you can do to help in organized
psychiatry and medicine.
If you are inclined to write, publish, or do research, private practice will
limit you only in terms of time available. Some of the most interesting pub-
lications come from psychiatrists who can write about their patient experi-
ences in real-world settings as opposed to carefully controlled studies.
Research opportunities abound as companies look for broad patient
groups, including groups in private settings, with which to do appropriate
studies. These studies may provide interesting scientific updates and offer
you the opportunity to be a part of well-designed research protocols. They
also will usually provide appropriate reimbursement for your patient care
so as not to significantly affect your income.
As you consider the proper balance between your professional life and
your personal life, make sure that you love what you’re doing in your work.
That’s the best advice possible if you want to have a gratifying professional
life. However, also make sure that you have time for your family, friends,
and significant others. Take care of yourself physically and psychologically.
Do all of the things that you would advise your patients to do to stay
healthy through proper diet, exercise, and attention to taking care of stress
in your life. While all of these suggestions are common sense, it’s important
to recognize that your success in a private practice will also depend on your
success in and appreciation for your personal life. If you have personal or
psychological problems, don’t hesitate to get treatment. Make sure that you
have colleagues to talk to about difficult patients, practice concerns, and
issues in your personal life that are affecting you. With these safeguards,
outlets, and attention to personal concerns, you can maximize your ability
to have a gratifying private practice.
❚ CONCLUSION
In the chapters that follow, you’ll first learn in the chapter by Roger Bonds
how to find a job in private practice. The multiple practice opportunities
and their advantages and disadvantages are covered in my chapter on the
many types of private practice. Next, Drs. Kersun and Silberman tell you
how to set up a private practice office. Then you’ll learn from Marcia
Brauchler how to market your practice. Learning the ins and outs of insur-
ance billing and relationships is the subject of Dr. Bennett’s chapter. Dr.
Luo outlines computer resources that can assist you in private practice.
Knowing how to relate to primary care physicians is the focus of Dr. Cole’s
chapter, and you’ll learn some of the legal pitfalls to look out for in Nancy
Wheeler’s chapter. In the final chapter, I’ll discuss some common ethical
problems and how to avoid or deal with them.
You can make your own list of advantages and disadvantages of private
practice and see how you come out in the balance. Sometimes starting a
private practice can be anxiety producing, but if it’s your passion to work in
a private practice setting, you will succeed.
2 FINDING THE BEST
POSITION FOR YOUR
MEDICAL CAREER—
AND YOUR PEACE
OF MIND
Each year we see thousands of graduating residents and fellows taking

their first jobs as practicing physicians. Most go into private practice; oth-
ers pursue careers in academia, research, and other rewarding areas. Every
young physician is excited about taking the next step in a promising medi-
cal career.
Although you will certainly have a gainful position as a psychiatrist, you
will want not only to have a job, but also have a career that is suited for you
personally and professionally in the location and community that are best
for you.
However, our research at The National Institute of Physician Career
Development now shows that the average graduating physician keeps his
or her first job for only 2.4 years (Bonds 2004). Because of this, many med-
ical organizations prefer not to hire a new graduate. They want someone
who has already made the first career move. But why is it that the brightest,
best-educated professionals in the wealthiest nation on earth prepare years
for a career only to find that the first position lasts such short a time? Let’s
examine the reasons.
9
❚ WHY THE FIRST POSITION MAY NOT BE A GOOD FIT

Lack of Planning
Did you know that research (Bonds 2004) shows that most graduating phy-
sicians literally spend more time planning their first vacations after gradu-
ation than they do planning their careers? For the vacation, they make
phone calls, search on the Internet, discuss options with colleagues, order
brochures, and have repeated conversations with their spouse or significant
other. But for their careers, they generally discuss options with colleagues
(the process known as networking) and then throw away most letters and
brochures that are mailed to them. Most never make phone calls to inquire
about advertised positions or conduct significant research on the Internet.
In the end, most young doctors take the position that falls into line the eas-
iest for them.
Poor Follow-through
Many newly practicing physicians also make the wrong career move by
making a decision that goes against what they originally wanted. For exam-
ple, the physician and spouse thought they would like to live in the Mid-
west, where they have been living for the last few years. However, an offer
of $20,000 more comes along and they jump at the chance to go to Phoe-
nix, a place they have never visited.
Changing Priorities
Once the newly graduated physician is in the new position and settled in,
we normally see a rapid maturation, professionally and personally. The
young doctor develops much more self-confidence in her clinical skills, as
well as in the day-to-day operations of the practice. If she travels to differ-
ent locations, she establishes a workable routine. If she is building referral
relationships with physicians and other providers, she gains confidence. As
she bills the insurance companies, she realizes what really can and cannot
be done to have her services paid fully and faster. In time, she understands
that she can confidently take these skills almost anywhere. The result of all
this is a young doctor who is now at a very different level professionally. Al-
though the partners or employers want this maturation, the young physi-
cian at this point often sees new horizons and moves on.
On the personal side, we see a similar maturation. This is a pivotal time
in the young doctor’s life, with a new lifestyle and new personal needs. The
single greatest determinant is having children and wanting to be closer to
Finding the Best Position for Your Medical Career—and for You ❚ 11
the extended family. Also, research (Bonds 2004) shows that for the second
job, a physician typically lives within 500 miles of wherever she or her
spouse calls home. (Home is defined as where the person grew up or where
his or her parents or other family members are now.)
Inaccurate Expectations
Matching expectations is always difficult, whether dealing with a patient,
spouse, or partner. In the case of the first job expectations, it is a difficult
challenge for each young physician to ask enough questions (and receive
adequate responses) to develop a realistic view of the new position. It is very
common for a newly practicing physician to walk into a new position with
a view of the job that differs dramatically from what the job actually entails.
The same is true for the employers’ or partners’ expectations of the new
employee. Each party expects something different. Problem areas can in-
clude hours or call coverage, pay scale, office space or location, support
staff, partnership track, and innumerable other possibilities. Although the
problem resides with both parties, the fact is that young physicians often
leave because the position simply was not what they expected.
Changing Relationships and Practice

When a practice or other organization brings in a young physician, the or-
ganization is by definition in a dynamic setting. That is, they are changing
and evolving, which is why they signed the new doctor. Ideally this will bet-
ter the organization, but often the dynamics do not work for the best. Per-
haps a managed care contract is lost. If the practice cannot support its
increased number of providers, it probably will cut the last one hired (“last
in, first out”). Additionally, the young physician should realize that profes-
sional and personal relationships change. The practice or department
members whom you adored at the outset may not be so likeable after you
have been with them for a couple of years. Stress and financial problems of-
ten strain these relationships, and the grass can then seem a lot greener on
the other side.
❚ FINDING THE RIGHT POSITION

Career Choice Priorities
Now let’s examine what motivates graduating physicians to choose that first
position. Of course, money is extremely important. Young physicians are
highly motivated to “catch up with the Joneses” and acquire large and small
belongings such as a house, cars, clothes, and much more.

However, most say that hours worked are far more important, so they
are willing to make a deal for less money if they can work fewer hours. But
that is usually wishful thinking. Newly graduated physicians quickly learn
that to earn a substantial income, as physicians normally do, they have to
work just as hard as their older colleagues, whether in private practice or
academia. The most significant exception to this pattern is the young fe-
male physician who takes a strictly hourly or part-time position so that she
can spend time with her children.
Geography is also a major determinant. Young physicians tend to move
first to a locale where they think they would enjoy living. For example, if
you enjoyed vacationing in Florida, you might take a position there or in
the next state, even though you and your spouse are from Chicago. Al-
though this might be your best decision in the short run, as you will learn
in the rest of this chapter, you can greatly reduce your newfound risk if you
don’t buy a house there right away and don’t overspend. Then, if you beat
the odds and decide to live there long-term, you will know exactly where
you want to live and will have the money to buy or build a wonderful home.
Employment with a guaranteed income and benefits is also a priority.
Young physicians want the security of a regular paycheck. Of course, most
academic positions are defined as employment. The salary may be lower
compared with the income from a private practice, but the benefits are usu-
ally much more robust. This security is a key reason so many young doctors
desire academia.
For private practice, the position may be contracted or solo, partner-
ship or employment. In each case, the base pay could be small or quite
large. A productivity bonus may or may not apply, and benefits may be very
good or nonexistent. A solo practice may have an income subsidy from a
hospital, or it may have no subsidy and therefore no income for the first
weeks or months.
To clarify definitions: Contracted means the physician is self-employed
and contracted to work with the practice. The pay could be a set amount
or could be based solely on production. Solo practice is defined as the phy-
sician’s being on his own (“self-employed”). Partnership is when the physi-
cian is actually an owner of the practice, but this is usually not an option at
first unless it is a new practice in which all the new physicians are made
partners. Employment means the physician is literally an employee of the
practice, which is the preferred model for most young physicians. A part-
nership option may then be available after 2 to 3 years.
It should be noted that going solo for the first position out of training
is a common option, although sometimes a difficult one. Many newly prac-
ticing psychiatrists who choose this option have outside assistance to set up
the practice. For example, hospitals often set up new practices. During the
first years, the hospital may provide subsidized office space, telephone, fur-
niture, office supplies, computer, and perhaps a shared receptionist and
billing coordinator. There are medical management companies and medi-
cal office buildings that offer the same services, but they do not subsidize
the services provided. Their business is to lease office space and provide as-
sociated practice services.
No Need to Learn the Hard Way

Newly graduated physicians often do not have the experience or have not been
taught some of the lessons that older physicians have learned the hard way.
First, it is imperative when evaluating a career opportunity that the
doctor consider the job’s total remuneration. This includes a set dollar
amount for the base pay, bonus or productivity pay, and benefits. It is as
simple as listing each item with a specific or estimated dollar amount and
adding up the total. Unfortunately, thousands of young physicians make ca-
reer decisions each year by considering only the base pay or salary. Here is
an example. For simplicity, consider all the other factors of these three
practices to be equal.
The graduating resident and spouse are from the upper Midwest and
are now located in Chicago. There is a practice opportunity in Milwaukee,
Wisconsin, offering a base of $100,000; a practice in St. Paul, Minnesota,
offering $95,000; and a practice in rural Illinois offering $80,000. At first
glance, most young psychiatrists are much more interested in the higher-
paying practices and probably will not consider the Illinois practice. But on
further examination, we find that the Wisconsin and Minnesota practices
offer no bonus and the benefits include only health insurance and three
weeks’ vacation. However, the Illinois offer is actually a base of $80,000,
with a realistic productivity bonus of $20,000, plus benefits that include
health insurance, 3 weeks’ vacation, 2 weeks’ sick time, paid holidays,
short-term disability insurance, long-term disability insurance, life insur-
ance, dental insurance, vision insurance, $3,000 continuing medical educa-
tion, and a retirement plan that contributes $15,000 per year. The total
package is well over $125,000 annually. Additionally, the cost of living is
significantly less in rural Illinois, resulting in a further enhanced income
level for the physician.
The next major mistake that we see young doctors make is buying a
home for their first career move after training. Quite simply, it usually takes
several years to break even on a home if you must resell it. If you fall within
the normal range and thus stay in the position for only 2.4 years, then you
will probably lose thousands of dollars. Adding these dollars to the thou-
sands you will spend on furnishing the home, plus insurance, upkeep, maid
service, yard service, and so on, it all totals up to a major loss at a time when
the young physician probably already has tremendous debts.
An exception to this rule may be if you are moving back to your home
town where you have much more confidence in staying long-term. Another
is if you are moving to a city where there are multiple opportunities and
you would not have to relocate if the first position turned out not to be per-
manent.
Of course, clinics and hospitals want you to buy a home so that they will
have you more grounded and you will have a major reason not to move
away. This is called “golden handcuffs,” and it is in their best interest, be-
cause they do not want physician turnover. Many of them will actually help
you arrange to buy a home with no down payment. This can be a great help
to physicians. But for newly practicing physicians, it is not a reasonable op-
tion because you will pay huge amounts of interest for years to come. Fur-
ther, you need to use your cash to pay off all your other debt quickly, not to
buy a house with the first job and risk losing a great deal of money. As a
newly practicing physician, you will probably earn a higher income than
95% of other Americans. At such a high income, you should then spend
only 3 to 5 years to get totally out of debt, at the same time finding out if
this first job is right for you long-term, and perhaps go on to become a
young millionaire. Unfortunately, most physicians pay off their school
loans over many years and continually borrow money for houses, cars, and
credit cards. Over a 10-year period, paying a quarter of a million dollars or
more in fees and interest to the lenders is not unusual. Hundreds of thou-
sands of physicians stay in debt for most or all of their lives.
An interesting book on the subject is The Millionaire Next Door (Stanley
and Danko 1996), also available on audiocassette. This best-selling book is
based on careful research and outlines who the millionaires are in America.
As the authors point out, physicians have been among the highest income
earners in our nation since World War II, yet a disproportionately small
number of them become independently wealthy, and most have to work
long into their later years for financial reasons. Their biggest loss of wealth
is due to acquiring large debts and then paying huge amounts in interest and
fees, instead of keeping their own money to live a dramatically enhanced
lifestyle while investing much of it for extreme wealth accumulation. To the
contrary, far less educated people who earned much less than the average
physician make up the overwhelming majority of our nation’s self-made
wealthy. Another best-selling book that outlines how to amass wealth (and
why not to buy a house at first) is Rich Dad, Poor Dad (Kiyosaki 2000); it too
is available on audiocassette. Perhaps the best motivator (to not spend all of
one’s money and still borrow more) is to remind the young physician of his
or her children’s future needs and to point out that the independently
wealthy are able to provide for their children and live a life of much less
stress and much more freedom than those who are not financially secure.
Deciding What Is Important to You

As you are considering your career options and where you want to live, it
is important to do your planning as discussed here. It is certainly not all
about money. You are consciously choosing the lifestyle you desire, profes-
sionally and personally. This planning should be done with careful thought
and introspection, and, if applicable, with involvement of your significant
other. It does not have to be difficult. Appendix 2–A is a simple form that
may be helpful.
This simplified approach to your initial planning should enable you to
clarify which practice settings you plan to consider and to lay aside the
many other opportunities that exist. This process also allows you to estab-
lish minimums, such as the minimum amount of money you must be able
to make, the practicing setting you must have, and the part of the country
in which you must live.
Notice that in section 2 of the form, you are asked to decide on a first,
second, and third geographical choice. Perhaps the first choice is a partic-
ular city, the second is the state, and the third is contiguous states. Remem-
ber to strongly consider the place that you and your spouse call home.
In section 3, you can define not only the practice type, but also the in-
come and benefits you desire (within reason). The practice opportunities
offering an array of benefits will normally be those with large organiza-
tions, including hospitals and universities. Also be sure to write down the
practice setting you do not want. Again, this helps you focus on the profes-
sional lifestyle you desire and prevent being burdened later by poor
choices.
Section 4 asks how much money you really need in order to have a good
lifestyle. If you earn $40,000 as a resident, perhaps after graduation you
could have a fine lifestyle at $65,000 per year. In the United States, that is
considered to be a very good income. You probably have a negative net
worth now (that is, you owe more than you have in assets). By maintaining
a moderate lifestyle like most Americans for just a few years, you then cat-
apult yourself into the class that has no debt and a six-figure income. Your
wealth can then go into buying a beautiful home (even if you then finance
much of it), or buying your own office building, or investing in stocks and
bonds, or establishing a 529 plan for your children’s education, or taking
time off, or donating to your favorite charities. Once you are debt free,
your wealth grows rapidly and dramatically.
Assessing the Opportunity

It is often a great surprise to young physicians to find they have chosen a
position that does not work out, through no fault of their own. Many posi-
tions do not even last a full year. For this reason, it is of the utmost impor-
tance to check out the opportunity and the physicians.
Just as the practice or clinic will check your references, you should
check theirs. Talking to their current physicians is a start, but the staff can
be just as important. Get a feel for how well the practice or department is
run. Is it well organized? Are certain managed care contracts or companies
a problem? If physicians have resigned, find out why. The list of questions
can be endless, but we advise you to trust your instincts. Think of each
stage in terms of green, yellow, or red flags—go, caution, or stop. If the an-
swers to your questions raise yellow flags, then ask more questions. If all is
green, then proceed.
If you are seriously considering the position, your job is to ascertain
whether the practice is as good as it seems and then to make a decision to
keep pursuing it or to walk away. This fact-finding process can greatly af-
fect your expectations so that you walk in with your eyes open and are not
blindsided by new information that affects your job. For example, if the
payer mix is largely managed care, are you being hired because of the addi-
tional managed care contract the practice has obtained? What happens if
the contract is lost? Will you be the last in and first out?
You can also ask for the financial information on your new partners or
employer—as your predecessors will have done in past years. The practice
will have “financials,” which include information such as the income state-
ment, profit and loss statement, balance sheet, cash statement, and ac-
counts aging report. Although a detailed discussion of this aspect is beyond
the scope of this chapter, it is advisable to have someone knowledgeable
look at such data to help you understand the numbers. If the practice hes-
itates, ask them what they would like to share, and mention that you under-
stand providing financial information for new physicians considering a
position is very common. You might need to tell them that it is all right to
remove the actual salaries or other confidential information. If they will
show you the financial information only in their office, ask if you can have
their manager sit down with you to explain it. You can also have your own
accountant or other professional go over the figures by phone to give you
peace of mind or to identify problems you need to know about, such as hid-
den debt. Although more and more practices are readily providing such
data, others are worried about this information being shared with the
wrong person. Note, however, that the strongest, best-managed organiza-
tions take just the opposite stance. They are pleased to have someone in-
terested and educated enough to ask such questions. Those who will not
provide financial data of any sort definitely raise a red flag. Those who give
limited information rate at least a yellow flag for the moment, but do not
walk away too quickly.
With a private practice, when you are at the stage of asking for financial
information you should always run a credit report on the business, just as
many prospective employers are going to run a credit report on you. To
check out the practice, go to the Internet address http://www.dnb.com.
This is the Web site for Dun and Bradstreet, the nation’s primary credit re-
porting company for businesses. At this writing, there are three levels of re-
ports. We recommend the mid-level, which costs about $100. The basic
level does not give enough information, and the advanced level is difficult
to read. The mid-level report offers good information in the form of out-
lining whether or not the practice pays its bills on a timely basis. Don’t
worry if all the bills are not paid within 30 days. But if the practice routinely
takes over 45 days to pay, that is a yellow flag. Over 60 days is a red flag. Re-
member, a yellow flag tells you to ask more questions, so don’t become eas-
ily discouraged. There may be a good reason for the delay, such as difficulty
in getting the managed care plans to pay faster—or you may have uncovered
the tip of a financial nightmare. If you want to find a reputable professional
consultant for assistance in evaluating Dun and Bradstreet credit reports
and other aspects of a practice’s performance, there are hundreds of consult-
ants nationwide, and some can be extremely helpful at a reasonable cost.
One might ask for referrals from other physicians. One might also look to
consultants who are nationally known for writing books and articles and for
teaching at conferences; these professionals are able to communicate clearly
and tend to be the most interested in helping young physicians.
Finding Opportunities
Again, your task is not only to find a position, but to find the position that
is best for you personally and professionally, that pays what you want, and
that is in the location you most desire. Most young doctors just fall into the
“best” position that presents itself.
The key to finding good career opportunities is to be proactive and to
start at least a year before graduation. The best positions are taken early on.
So when you see something of interest, move quickly, because it probably
will not be available for long.
Be careful not to listen to those who claim that the best positions are
not advertised or promoted in any way and therefore are inaccessible.
Many times those not advertised are indeed the best positions—and all you
have to do is apply for the job.
To find your best career opportunities, we strongly recommend that

you continue true networking—but not rely on it exclusively as many do.
Networking is the process of asking who knows of a position, or where the
need for a psychiatrist may be, and then calling or e-mailing the proper
person directly. Mailing a letter when you hear of a position is usually not
effective, except for academic positions that have a more formal hiring sys-
tem. Sending an e-mail may net some result, but making a phone call is
much better.
Go to the career center of the American Psychiatric Association (APA)
for outstanding help in finding a position. You can post your curriculum vi-
tae and also search job postings. Attend the annual meeting and visit the
booths for those who are recruiting psychiatrists. Remember, there are
plenty of opportunities. You just want the one that is best for you.
Next, comb the APA and other psychiatry publications for recruitment
advertisements and follow up promptly. Ads also appear in non–specialty-
specific publications, such as JAMA, New England Journal of Medicine, and
Medical Economics. All of these journals also have the jobs posted on their
Web sites, often before the magazine is published. If you get to those ad-
vertised positions first, you have a much better chance of being inter-
viewed.
Opening your mail and quickly reviewing the recruitment pieces re-
ceived can also present fine opportunities. If you have done the basic plan-
ning recommended here, this should be a quick and simple task. If the
location is what you prefer, and if the practice setting is appropriate, re-
spond immediately.
Accepting phone calls from recruiters may offer you the opportunity
you desire. Remember there are search firm recruiters (headhunters) and
employee in-house recruiters. The in-house recruiter is employed by the
clinic, hospital, or health maintenance organization to find qualified, inter-
ested physicians. Many of these recruiters will call you after doing careful
research. They may already have your curriculum vitae from the APA or an-
other service, and they may be calling on behalf of a physician who has asked
them to locate you. Search firms may be less desirable, but if you do take re-
cruiters’ calls, we advise you to quickly take control of the conversation and
ask the questions that will tell you if there is an opportunity that fits your
needs (such as the practice setting and the location of the practice or hospi-
tal). If the job does not meet your needs, you can be off the phone in 60 sec-
onds. If it does meet your needs, then the possibility is open, even if you ask
the recruiter to call you back or e-mail you. In any case, once you have es-
tablished contact for a position of interest, get past the recruiter and speak
with the physicians or administrators. The best recruiters want that, too.
Using Internet sites set up specifically to list physician opportunities
TABLE 2–1. Key words for Internet search

• Physician + Physician + City and/or state + • Practice
• Medical staff • Opportunities
• Doctor • Placement
• Search
• Recruitment
• Jobs
• Positions
can be an easy way to find positions. They charge a fee to the clinics and
other employers who post the jobs, and there is no charge to you. There
are many such sites, including these three that may be of interest:
• http://www.PracticeChoice.com
• http://www.PracticeLink.com
• http://web.medbulletin.com/Webodrome/jobHome.php
Searching the Internet can help you find more positions. Use the key
words shown in Table 2–1. For best results, choose one word from each of
the four columns. Currently, Google appears to be the best search engine
for this purpose.
Going to physician recruitment exhibits can also present good oppor-
tunities. You may go to a national APA meeting or attend a state meeting.
Also check what is available in your present area or in the area to which you
want to move. Often there are recruitment fairs within a particular state
that you may not hear about unless you search the Internet or make contact
by e-mail or telephone. Possible contacts include the APA district branch,
the state medical society, and city or county medical societies.
❚ DEALING WITH PROSPECTIVE EMPLOYERS

How Much Are You Going to Pay Me?
Regarding how much a position pays: With search firms, we recommend
that you ask that question right away. With all others, be very careful. If you
have called to inquire about a position, or if the employers have called you
or e-mailed you, it may not be in your best interest to ask about pay during
the first conversation. After your curriculum vitae has been forwarded, and
perhaps after they have sent you information, then if they do not bring up
the subject of pay it’s entirely appropriate to ask, if it is done properly. You
definitely should ask before you travel across the country for an interview.
If you are traveling only across town, or an hour away, perhaps you will wait
until you meet them in person for the interview.
A proper way of putting the question might be, “By the way, can you
give me an idea of the approximate range of pay a psychiatrist might earn
in this position? Is there a production bonus on top of that? Can you tell
me about the benefits?” Notice how the first question is asked with various
qualifiers for a more gingerly approach to the question—words like “give
me an idea,” “approximate range,” “might earn.” The way you ask is para-
mount to obtaining the information without offending.
Prepare for Your Site Visit and Interview
Some organizations will almost immediately ask you to come for an inter-
view. Others may want to consider many candidates before they respond to
you and may even conduct basic credentialing and background checks be-
fore meeting you in person.
From the hiring organization’s perspective, there are two purposes for
the visit. The first is to interview you to see if you may be the right person
for them, and the second is to put their best foot forward to convince you
to take the position. If you are interviewing locally or within a few hours’
drive, these two functions may be broken out into separate visits. If you are
interviewing from further away and staying overnight, the one visit proba-
bly includes both functions.
You will want to visit only those locations in which you have substantial
interest, so choose carefully and prepare yourself as much as possible. You
may start your preparation by asking various questions about the practice,
department, hospital, fellow psychiatrists, and referring physicians. Ask the
organization to send you as much information as possible about itself and
the community. You should have one or more conversations with physi-
cians by telephone. Do your research on the Internet as well. If you have
to, take this information with you on the plane and read it there. Be sure to
ask what to wear. Some will expect a nice dress or suit, so dress the part.
You may need to purchase clothing and shoes for the occasion.
Be sure you have asked good questions prior to the interview, and be
prepared to ask many more questions when you are there. This is no time
to be quiet, even if that is your usual style. Also, realize that you need to put
your best foot forward. At this point, humility is highly overrated. If you
don’t tell them you are a fine psychiatrist, your competition may very well
get the job.
If your significant other will be going with you, coach him or her to ask
good questions also, possibly about the community. If your significant
other will be looking for a job in the vicinity, ask ahead of time if he or she
can interview at a couple of places during the visit. Dual spouse recruitment
is very common, and the employer may be happy to set up courtesy inter-
views in your spouse’s field.
After the interview, follow up with at least an e-mail to say thank you.
Or you may prefer to write a letter. Ideally, write each of the decision mak-
ers, or at least the key person such as the group’s senior physician or the de-
partment head.
If you think you may want the position, be sure to ask at the end of the
visit what the next step is. When you write or call afterwards, politely ask
this question again to keep the ball rolling and to give you an idea what to
expect.
Avoid the Process of Elimination

Although the interview is one way for the organization to screen out can-
didates, there are other screens that you should be aware of, and some may
be done even before you interview. Screens may include the following:
• Credentialing. This, of course, includes the verification of your educa-

tion, licensure, and Drug Enforcement Administration number and a
check of the National Practitioner Data Bank. Years ago this was
thought to be all that was needed. But today there is much more.
• Credit check. A permission form will be presented to you to sign for this
check. The employers want to find out whether you are a responsible
person and whether there are any yellow or red flags because you evi-
dently have personal financial problems. If you have any adverse history,
be sure to tell them before they run the report; this will minimize the
negative information. It is best to check your own credit ahead of time.
• Criminal and civil courts checks. These are two separate court systems in
our country, and an organization will often have both checked for all the
states and counties where you have lived to see if you have been con-
victed of crimes or involved in lawsuits.
• Driver’s license check. The organization will be primarily looking for drug
and alcohol abuse, but also for multiple speeding or other driving tick-
ets. Again, they do not want to hire someone who is a “problem.”
• Professional and personal references. You may be asked for three of each. Al-
though you may coach your referees in what to say, if the employers
think the references sound too coached or if they perceive any yellow
flags, they will seek additional references as well.
• Physical and drug screenings. The larger organizations are routinely re-
quiring these screenings. Smaller organizations usually do not.
• Malpractice carriers check. The organization will check your current and
past carriers, with your permission, to see what litigation may have oc-
curred.
• Workers compensation check. Here the employers will be looking at public
and insurance company records, with your permission, to see if you have
taken time off for workers comp.
Get It in Writing
We have all heard that one must “get it in writing or it does not exist.” For
a newly hired physician, this applies as well. We strongly recommend ask-
ing that all salient points be addressed in writing, as part of the contract. If
it feels uncomfortable to request this, then ask for confirmation in the form
of a letter or e-mail. If this is still not appropriate, and if you are going to
accept the position, then write an acceptance letter saying you are accept-
ing the position based on this understanding. Ask them to respond to you
by a certain day if this is not their understanding. And above all, be courte-
ous, professional, and grateful for the opportunity they are affording you.
❚ CONCLUSION
The opportunities for newly graduated psychiatrists abound. With private

practice positions in every region of the country, it is not a matter of finding
a position, but of finding the best position for each physician. In this chap-
ter, I have reviewed the need for careful planning and for considering the
various practice settings that are available, including going solo. The first
position, on average, will last 2.4 years. Therefore it is imperative to make
careful decisions regarding which position to take and not to overspend on
housing and other significant expenditures.
The initial planning process can be simplified with the planning form
provided in this chapter, and this process should identify the geographic ar-
eas and practice settings of interest. Finding the best position may be as
simple as networking, but often it will be a result of searching the Internet,
responding to advertisements and recruitment letters, and speaking with
search firms and in-house recruiters.
A strong word of caution to the physician candidate is to consider care-
fully the pros and cons of each practice and community. Researching on the
Internet and asking good questions can help in this regard. Obtaining a
Dun and Bradstreet credit report on the private practice is recommended.
A professional who is experienced in such matters should review the con-

tract and related financial information.
The best positions will probably have numerous applicants, so the in-
terviewing physician should prepare carefully and realize that the clinic or
hospital may conduct a background check that includes a credit check, a
driver’s license check, and more.
❚ REFERENCES
Bonds RG: National Physician Career Survey Report. Atlanta, GA, American
Academy of Medical Management, 2004
Kiyosaki RT: Rich Dad, Poor Dad. New York, Warner Books, 2000
Stanley JT, Danko WD: The Millionaire Next Door. Atlanta, GA, Longstreet
Press, 1996
APPENDIX 2-A
Planning Your Career Search
(If you have a significant other, all questions must be considered for both parties.)
1. Where are the jobs currently? Geographically and in practice setting type?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2. Identification of the geographic setting you prefer.
First choice: _____________________________________________________

Second choice: _________________________________________________
Third choice: _____________________________________________________
List states or regions you do NOT want to live in:
______________________________________________________________
______________________________________________________________
3. What type of practice setting and income do you desire (i.e., six-physician free-
standing group @$110,000 plus reasonable benefits and income potential, or
full-time employment with large managed care company @$95,000 with full
benefits and limited hours and call)?
Practice Setting Income

First choice: ___________________________________________ $_________________
Second choice:_________________________________________ $_________________
Third choice:___________________________________________ $__________________
Type of practice setting you do NOT want:_______________________________________________
4. What is the least amount of money you need to make to pay off bills and live the
lifestyle you prefer? $_____________________________________________
(Don’t forget cost of living differences in the offers you consider.)

3 THE MANY FACES OF
PRIVATE PRACTICE
After you have made the decision to enter private practice, it also makes
good sense to consider the numerous types of private practice that are
available. Although many people have an image of the individual psychia-
trist in a single office with a waiting room, that is not the only type of pri-
vate practice available. Indeed, there are many forms of private practice
that open up a range of opportunities for those starting on this course. In
this chapter, I’ll discuss the advantages and disadvantages of some different
practice arrangements, the likely types of patients in various settings, sub-
specialty influence, physician networks, and lifestyle issues.
❚ PRACTICE SETTINGS
There are five general practice settings in the private sector:
1. Solo practice
2. Small psychiatric group
3. Large psychiatric group
4. Multidisciplinary group
5. Multispecialty group
Solo Practice
First, and still the most common for private practice psychiatry, is the solo
office-based psychiatric practice. Solo practice has a number of distinct
27
advantages. One is the complete autonomy that you have in solo practice. You
call all the shots regarding where and when to practice, how much to work,
how to arrange your office, and any other details about your professional
life. When changes need to be made in any of these, it’s you who ultimately
decides. So decisions and changes that are made are always consistent with
what you value. A corollary advantage is that you have control over which
patients, and how many patients, to serve. Some psychiatrists will choose
to see only individual patients in psychotherapy, or in psychotherapy and
medication management, whereas some will choose to have a psychophar-
macology practice only, leaving psychotherapy to others. Some psychia-
trists will see a mix of individual patients, couples, families, and groups. You
can make these choices on the basis of needs in the community served and
also according to your competencies.
Another advantage of solo practice is that you have both business and
financial control over your practice. All of your decisions are your own,
made by yourself or with advice from family, friends, or consultants. You
decide how to set up the business, billing, and accounting aspects of your
practice. You also have authority over all of these functions, and it is your
responsibility to know what is happening on the business side of your prac-
tice. This business oversight will affect your income and expenses, and you
will be in the best position to know the details of what is going on finan-
cially.
You will also determine whether or not to hire any office staff. In a busy
practice, it is often quite helpful to have part-time or full-time staff to per-
form general office duties such as answering the phone, opening mail, and
keeping up with other regular office details. Of course, staff assistance
comes with a cost, but in the long run it may save you time to be more pro-
ductive in your income-generating work.
The final advantage of solo practice is the ease of change. If you believe
change is warranted, it’s your decision whether to move offices, change
staff, alter the patient mix, or change any number of other parameters of
practice.
On the other hand, there are also some disadvantages to solo practice.
Mentioned by many is the relative isolation that comes with private prac-
tice. After one has finished residency training or work in another type of
setting, a solo private practice can be very isolating. Although there can be
great pleasure and satisfaction in treating patients hour after hour, many
people also like the ability to interact with colleagues for professional or so-
cial reasons. The more physically isolated the solo office, the more poten-
tial there is for isolation from other people. Breaking up the practice day
with activities that involve others can mitigate this, but it does take plan-
ning and is not part of the everyday office experience. Some enjoy the full
The Many Faces of Private Practice ❚ 29
patient day and reserve their professional interactions for evening meet-
ings. In short, there are ways to augment professional interaction, but it
takes some effort.
One final disadvantage is the relatively increased fixed costs of a solo
practice. Because all expenses are borne by one person, your staff, billing,
phone, accounting, faxing, rent, and all other office-based expenses are
your responsibility. Although you may have better control as an individual,
you may find that these practice expenses eat away too much of your in-
come.
Small Psychiatric Group

A small psychiatric group, for purposes of this discussion, is from two to
four psychiatrists. There are a number of advantages to this type of practice
arrangement. First, there is the opportunity for collaboration, either in a
formal way or in the time-honored “curbside consultation.” When two to
four psychiatrists share an office suite, they will inevitably come across each
other in the waiting room, in the hallway, or in their administrative space.
Although discussions about patient issues need to be carefully monitored
so that there are no confidentiality breaches, it’s very easy in the small
group practice to go next door and ask a question, get a scientific update,
or keep up your personal relationship. Some small group practices set up
regular scientific practice updates by either having a journal club, inviting
in guest speakers, or doing their own case presentations.
Another advantage to a small psychiatric group is the ability to share
fixed costs like office rent, waiting room space, office staff, and office
equipment and telephone or other business services. Some small psychiat-
ric groups have also invested in their own buildings, which they use for
their own practices or rent out to other professionals. A small psychiatric
group also may be better able to negotiate with third-party payers for fees
or payment terms than an individual psychiatrist might.
If there are good working and professional relationships in the small
group, the possibilities for interoffice referral are very high. When one
member of the group is too busy or thinks another can handle a particular
case better, it is far easier to chat with someone down the hall than to call
someone outside the office to make the referral. Knowing and respecting
each other’s abilities will of course determine the extent of interoffice re-
ferral, but this possibility does not exist in the solo practice. It also may be
easier to set up cross-coverage with others within this office setting than it
might be if you needed to find colleagues outside the office.
There are also some disadvantages to small group practice. Because
decision making is shared, time must be set aside to reach consensus on
important business or practice choices. The ability to compromise is defi-

nitely a desirable attribute, and without it, this type of arrangement is
doomed. If you’re fiercely independent and it’s no way but your way, then
don’t go this route.
You also need to keep in mind that there may be increased investment
costs in a small group practice. The group may decide to purchase office
equipment that is either more complicated or more expensive than the type
you would purchase as an individual. You may need to consider investing in
a building, providing benefits for office staff, or making other financial
commitments that would not exist in a solo practice. Once you’re in this
type of practice, extracting yourself may be cumbersome, and you may be
obligated to financial expenditures that you hadn’t expected.
Large Psychiatric Group

Here I am referring to any group above four. The advantages are an exten-
sion of those in small group practice. The ability to have greatly increased
collaboration among colleagues is an advantage. Many larger psychiatric
groups will have members with varying expertise in subspecialty practice,
with the result that intraoffice referral is greatly heightened. Of course,
with the increased numbers come increased opportunities for on-the-spot
consultation on patient care questions.
With increased numbers comes the ability to share fixed office costs
with a larger group and ideally be more cost-efficient for each member.
Spreading the financial risks among more individuals should ultimately
lessen individual expenses. The larger the group, the greater the ability to
negotiate with payers. In addition, office staff will be a necessity, and costs
can be shared.
With the larger group, however, comes the increased time it takes to
maintain the collaboration, especially for the business side of the practice.
Issues related to how decisions are made in a large group and the complex-
ities of group dynamics begin to play a role. Think of group conflicts in
your residency or medical school and you can be sure that some types of
group conflicts will play themselves out in this setting as well. To get you
through the tough times, it’s important to have good processes in place,
good professional relationships, a good sense of humor, and at least some
social appreciation of each other. Good and binding ties are necessary when
thorny issues come up. For example, if you all own a building together,
make sure that your partnership agreement will stand any kind of test in the
event of a partner’s death, disability, retirement, or wish to sell. Having a
trusted attorney picked by the group for these purposes is critical.
With the larger group comes the potential for larger investment costs.
If you’re part of the large group and they decide to purchase a computer sys-
tem that you think is too costly, you may need to go along with the decision
even though you don’t totally agree. Compromise, negotiation, and good
interpersonal processes get large groups through these thorny dilemmas.
With a larger group, the ease of change also diminishes. Because you
need to assess the wishes and needs of a larger group, changes may come
more slowly than you might like. This can either work for or against you
in the end.
Multidisciplinary Group Practice

Here I am referring to a mental health professional group consisting of a
mix of psychiatrists, psychologists, social workers, and nursing practitio-
ners or others. In such a group, there will be multiple opportunities for in-
teroffice referral and collaboration. Often in such a group, the psychiatrists
may take on the more complex psychopharmacology cases and collaborate
with the other professionals who are doing psychotherapy while the psy-
chiatrist is providing the medication management services.
There is no one ideal model in such an arrangement, and some of these
practices just grow over time as professionals get to know each other in the
community or when they work closely together on cases. The range of ser-
vices that can be provided in such a group practice is significantly greater
than in a psychiatry-only practice. Often, therapeutic modalities may be
provided by the other professionals that are not part of the usual psychia-
trist’s armamentarium. The opportunity to do conjoint treatment or co-
lead groups is another possibility.
The advantage of sharing of fixed costs is present, but this may become
more complicated with a different mix of professionals. For example, the
psychiatrists might want to have a nurse available to draw blood for labo-
ratory tests, whereas the non-M.D. professionals might not find this a good
investment. The other potential business advantage of this type of group is
the ability to provide a place for “one-stop shopping” for all mental health
services (assuming you offer most of them). Your group may be able to rep-
resent itself to third-party payers, referring physicians, and others as a place
where almost any type of patient can be referred and treated.
With the increased size, however, come some potential disadvantages.
There will inevitably be increased time for collaboration and decision mak-
ing. If you are in an employer or supervisory relationship with some of the
other professionals, there are increased legal, ethical, and business ramifi-
cations. Consultation with a good practice attorney, accountant, and/or
business consultant will be critical. If you all share in decision making, then
there may be group dynamic issues. Again, the need for compromise and
consensus is essential to success.
In addition, the complexity from a business point of view necessitates
that at least several members of the group have some business or financial
skills to make sure that your business decisions are sound. It may make
sense, if the group is large enough, to hire an office manager with these
skills to manage the routine business issues while the professionals provide
guidance and oversight. All of these points of decision may involve costs or
investment, and you should be prepared to approach a multidisciplinary
group with the appropriate questions to see whether it fits in with your
style and interests.
Multispecialty Group
I am referring here to a group made up of mental health professionals as
well as physicians or professionals from other specialties. In addition to all
of the advantages of the multidisciplinary group, this type of practice offers
possibilities for more integrated care of patients. This might be advanta-
geous especially for patients with comorbid medical problems, those with
chronic illnesses, or complicated cases requiring multiple specialists. Such
a practice will inevitably have a more “medical” feel to it, but for a psychi-
atrist who enjoys working with complicated cases and working closely with
other physicians, this may be an ideal practice situation. In addition, the
opportunities for ongoing collaboration and medical education will un-
doubtedly be increased. Such a setting exponentially increases the oppor-
tunities for “curbside consult,” referrals, and practice-building.
If you enter such a practice as a co-owner or partner, you will have the
benefits of sharing broader and perhaps more efficient practice expenses. A
multispecialty group will also have increased clout in contracting with pay-
ers and may be able to present opportunities for education, research, and
practice incentives that may not be available in a smaller practice. A multi-
specialty group will usually have good business support services that relieve
the professionals in the group from the business burdens of a smaller prac-
tice.
With the larger size, however, may come some disadvantages. It may be
difficult in such a setting to say no to a referral, so your ability to control
your patient type and flow may be diminished. In addition, you will have
much less financial control as a member of a large group, and your voice
will be only one of many. Other specialists may have other needs resulting
in costs to the group that you would not ordinarily invest in if your practice
were strictly psychiatric. For example, there may be imaging services that
may generate a cost to you but for which you have limited needs. Your pro-
fessional and business autonomy will then be captive to a much larger de-
gree to the larger group, and you will have to be prepared to adjust.
The business and financial decision making of this type of group will
also be more complex, and the time to oversee, review, and come to con-
sensus may be substantially greater than in the other types of practices.
As you think about the types of private practice and whether any of these
are particularly appealing to you, make sure that you find psychiatrists in
these types of practices to talk to. Ask them tough questions about their
views of the advantages and disadvantages, what they would have done dif-
ferently, what you should look out for, and whether they would do it this
way again.
❚ PATIENT/PRACTICE TYPE
It’s important to recognize that there is no “one size fits all” in private prac-
tice. One can do outpatient, inpatient, consultation, evaluation, and any
other number of combinations of these types of work in practice.
Although this book will not attempt to cover the range of subspecialties,
it is also important to recognize that different subspecialties in psychiatry
may put their own stamp on a private practice. For example, if you’re a
child psychiatrist, you’ll likely need a different office setup with a play-
room. If you are a geriatric psychiatrist, you may want to have special pro-
visions in your waiting room, or you may need office staff to assist the
elderly with filling out forms or interacting with other treating physicians.
If you’re a forensic psychiatrist, it’s possible that much of your work will be
done away from your office, for example in a jail or prison. If you’re a con-
sulting psychiatrist, much of your work may be done in the hospital. All of
these examples illustrate the complex and multifaceted nature of private
practice and the need for careful research and advice on determining the
best practice milieu and setup for you.
❚ PHYSICIAN NETWORKS
There are many varieties of networks that psychiatrists can join either for
referral purposes or as a provider. The types of physician networks are in-
dependent practice associations (IPAs), preferred provider organizations
(PPOs), health maintenance organizations (HMOs), and behavioral health
companies or carveouts. All of these entities have advantages and disadvan-
tages for psychiatrists.
In brief, the more integrated the network (such as integrated patient

records, outcomes, or coordinated care), the more you will have the advan-
tages and disadvantages of integration. The more integrated the network,
the less autonomous you are, but you also may benefit from economies of
scale, negotiating clout, and contract management that will not be available
if you’re in a smaller practice. Much information is available to psychiatrists
on the American Psychiatric Association Web site at http://www.psych.org/
psych_pract/. The American Medical Association has considerable infor-
mation through its Web site at http://www.ama-assn.org. On that site, look
under “Professional Resources” for “Practice mgmt. tools.” An excellent
model managed care contract is also available at that site under “Profes-
sional Resources.” State medical societies usually have information avail-
able to help practicing clinicians with information pertinent to that state
(and may also require membership). A thorough understanding of the ben-
efits and risks of joining one of these organizations is critical. We have seen
over and over that psychiatrists and other physicians will sign contracts
without reading them thoroughly or getting legal advice, will accept fee
structures that they are uncertain about, and will not take advantage of any
negotiating ability they may have. Remember, talk to more experienced
colleagues, research the network, and don’t sign contracts for networks
without understanding the nature of your resultant obligations.
❚ LIFESTYLE ISSUES
As you think about the type of practice setting that you want to work in,
you should also make a careful assessment of how your practice choice will
influence your personal life. The practice settings described in this chapter
also have effects on one’s personal life, ranging from the ultimate flexibility
of the solo practice to the potential complexities of a multispecialty group’s
demands. Remember that your autonomy diminishes as you increase the
numbers of people you work with. Although you many enjoy the cross-
coverage in a larger group, you may also dislike the increase in the number
of calls you have to take when you’re on call. If you are doing a more pre-
dominantly hospital consulting or medical clinic type of practice, you may
need to be more immediately available to go to the hospital or clinic and
possibly interrupt your day. Likewise, if you have a mix of outpatients and
inpatients, you may need to juggle your schedule regularly to make things
work.
As mentioned in the introductory chapter, there are multiple opportu-
nities to interact with other psychiatrists and physicians when you enter
practice. You are usually invited to attend grand rounds or other educa-
tional opportunities at your local university medical center. You can take
advantage of hospital, medical society, or psychiatric society educational
meetings. If you are interested in volunteering, there are numerous places
where your services would be welcomed, such as in clinics for the homeless,
clinics or services for the uninsured, and services through religious organi-
zations. You will always be welcomed to join activities through county or
state medical societies or the district branch of the APA.
If you have a particular interest in the political aspects of health care,
there are the possibilities for physicians to take training through the Amer-
ican Medical Association Political Action Committee (AMPAC) on how to
run a political campaign. You can learn more about these programs at their
Web site: http://www.ampaconline.org. You can enrich your education and
experience through various online educational programs leading to degrees
in business, management, or finance. If, as part of a practice, you decide
that you need more business education, you can seek further education
through medical organizations or through college programs in your city.
Although time management can be tricky, don’t stop learning to im-
prove your professional and business competencies. The key is to pick
those educational activities that will make a real difference in your profes-
sional or business life. You should strive toward always being the best psy-
chiatrist possible while improving your ability to make an adequate living
with the least hassles.
To round out your volunteer activities, consider joining a committee,
whether of a hospital staff you are on, through your county or state medical
society, for your district branch of the American Psychiatric Association, or
for your subspecialty organization. These organizations always need volun-
teers and involvement, and it will help you to keep in touch with psychia-
trist and physician colleagues and benefit your profession. You might also
consider leadership opportunities in these organizations if that’s your bent.
Finding professional activities to supplement your patient practice can
make your professional life more fulfilling.
❚ CONCLUSION
I hope you can sense the broad range of possibilities that await you in pri-
vate practice. The combinations that will lead to a gratifying professional
life are endless, and you’ll certainly need some time to find the combination
that is right for you. It’s also quite possible that you’ll make a few changes
in your practice setting as you sort through what works best for you.
Remember in the end that if you love what you do, you’ll make the most
of your training as a psychiatrist.
4 THE PSYCHIATRIC
OFFICE
S etting up an office is an important and central aspect of getting started

in private practice. This step in career development can seem forbidding
and is often laden with anxiety. How is an office created when none cur-
rently exists? On the one hand, this is a very simple matter; one needs a
small office with a waiting room, a phone, an appointment book, and mal-
practice insurance. Indeed, when conceptualized in this way, there is an el-
egant simplicity to the whole endeavor. On the other hand, there are a lot
of practical details that need to be addressed as one plans and executes set-
ting up an office. Moreover, setting up an office is usually a quantum jump
toward autonomy. It can be frightening to separate from the familiar insti-
tutional setting of medical school and residency and create your own space.
At the same time, having your own office can be an enormous source of
pride and gratification. In this chapter we address the specifics of setting up
an office in an effort to help the graduating resident pursue this process in
a thoughtful and thorough fashion.
❚ LOCATION
The area where you decide to practice is an important consideration; it is

likely you will remain in that area for many years. It is important to be able
to feel that this area is a place where you would enjoy working. Here a little
37
bit of research and some careful thought go a long way. Choosing an area
in which to practice is not unlike choosing a significant other; there is a
chemistry and compatibility that, when present, go a long way toward help-
ing a practice flourish. You need to consider, also, whether the area is a
place where you would enjoy living. Enjoying the location will positively
affect the growth and development of the practice.
Many complex factors are involved in choosing where to practice. Some
were noted in earlier chapters: Do you have a commitment to a particular
area? Do you like a rural, a suburban, or an urban setting? Is a particular
geography and climate preferable? There are other factors as well: Is the
population of a particular area going to be able to support the type of prac-
tice you want to establish? A fee-for-service psychotherapy practice usually
requires a different socioeconomic milieu than an insurance-based prac-
tice. Ongoing fee-for-service psychotherapy is expensive; a patient needs to
be psychologically amenable to and financially able to pay for his or her
treatment. Many patients are not so inclined, even if the therapist is willing
to be flexible with the fee. Therefore, a fee-for-service psychotherapy prac-
tice, in all likelihood, needs an upper middle class population base in order
to develop successfully. Similar considerations apply if you are setting up a
general psychiatric practice. Because patients in a general psychiatric prac-
tice tend to be seen less frequently, the cost burden to the patient tends to be
less. Therefore, it is probably somewhat easier to establish a fee-for-service
general psychiatric practice. However, if you are planning on accepting in-
surance, the socioeconomic milieu of your office is less of a pressing con-
cern.
There are other questions that need to be asked as well. What is the
psychiatric community in the area like—is it collegial and collaborative, or
is it more competitive and turf oriented? In general, it is a good idea to call
several psychiatrists in the area that you are considering and speak with
them about their practices. Learn about how they practice: How frequently
are patients seen? What is the length of a session? How much of what is
done is pharmacologically oriented versus psychotherapeutically oriented?
If psychotherapy is practiced, what type or types? Do the physicians have
good relationships with the other psychiatrists in the area? Ask them
whether they take insurance and if so, which plans. Inquiring about fee
structures can be a delicate subject. Some colleagues will volunteer this in-
formation in an effort to be helpful to you; others will not. You can safely
ask good friends and recent graduates about what they charge to get a sense
of pricing. Ask other psychiatrists if they have employees and what the em-
ployees do for them. How much do they pay for rent? If someone is resis-
tant to answering these questions, the individual might feel threatened by
new competition. Encountering resistance from several psychiatrists will
The Psychiatric Office ❚ 39
tell you a lot about the psychiatric milieu in the area.

You need to know what kinds of resources are available for psychiatric
hospitalization and where patients are referred for crisis intervention. It is
a good idea to consider what kinds of public transportation are available in
a given area. In an urban setting, it is quite possible patients will need or
want to use public transportation to get to your office. You might consider
an office location near a train or subway stop. Even in suburban practices,
patients might wish to get to your office by train or bus if this is an option.
Another good thing is to check out the medical hospitals in an area. See
how many psychiatrists are on staff. If many psychiatrists are already prac-
ticing in an area, that is not a contraindication to opening an office; it is
merely a variable to consider. The truth of the matter is that a good and
savvy psychiatrist will succeed no matter the degree of saturation; it might,
however, take somewhat longer to become established. If you are relatively
open-minded, ambitious, able to take advantage of opportunities when
they are presented, dedicated to providing excellent care, patient, creative,
and relatively flexible, you will likely succeed wherever you open your prac-
tice. Indeed, there is certain wisdom to the expression “If you build it, they
will come.”
❚ OFFICE
Once you have decided on a particular area, you then need to obtain a space
in which to practice. You need your own office, quite an exciting idea. The
options here are many. If you are considering joining the staff of a local
hospital, there is often an office building associated with the hospital.
Sometimes an office in such a building can be rented on a part-time basis.
Also, there are usually physicians—not only psychiatrists—looking to sub-
let some of their space. One can rent one’s own office in a medical office
building, but this does tend to be quite expensive. You can get the informa-
tion you need about such spaces by contacting the administration at the
particular hospital. Having an office in such a building has the advantage of
placing you directly in a medical community where you can easily get to
know other physicians to begin to establish a base of referral. If you are go-
ing to be doing hospital consultation work, an office in a medical office
building is extremely convenient; you can easily do a consultation in be-
tween patients. This milieu is also helpful from a social standpoint in that
solo psychiatric practice can be somewhat isolating and lonely.
Another option for an office is a professional building. Most areas have
many such buildings. This type of office can have the social and collegial
advantage of the hospital medical office building, and it tends to be less
expensive. One way to find out where these buildings are is to call the office
of the local government—town hall or borough hall—and ask for a list. You
can also simply drive or walk around a neighborhood that you like and that
seems to be commercially oriented. Look for “office for lease” signs. Write
down the number and give the person a call. It can be quite fun and surpris-
ing to explore and see what you learn.
If you want a less traditionally medical type of office, one that is more
personal and homey, this random wandering around approach can often be
quite fruitful. One of the authors came across many interesting options in
this way. One such option was subleasing some space from a law office in a
building from the Revolutionary War period. You might also consider rent-
ing a one-bedroom apartment and converting it into a psychiatric office.
This option can be very affordable and provide space that is very attractive.
It is always nice to have a kitchen in which to store lunch food, soda, and
coffee. The advantages of this type of space are many. The space is dis-
tinctly private and does not have the “medical office” look. Patients often
find this very comforting and appealing, which can be a good thing when
you are trying to establish a place where people can feel at ease and trusting.
This type of office also affords a lot of latitude in terms of how the space is
decorated. It is important to ascertain, however, if zoning regulations in the
particular location can permit medical practice. Again, the local govern-
ment office can provide this information.
Another option is building or purchasing an office building or space.
This can be done alone or with others. There are many advantages to own-
ing your own space from a tax and investment standpoint. However, it is
probably better to get settled into your new practice before entertaining
the purchase of real estate. There is much to be learned in the initial years
of practice; owning business real estate adds more to the already large pile
of things that you need to learn and know about. After you have been in
practice for several years, you might consider purchasing your own space.
By this time you will be familiar with the area and will know other profes-
sionals with whom you might want to partner in a business venture.
Finally, if you purchase a home, having a home office is also a possibil-
ity, assuming that a portion of the home could be configured for such a pur-
pose. In all likelihood a separate entrance will be required for patients, and
there will need to be space that is dedicated specifically to the office so that
the office boundaries are clear to both the patient and the psychiatrist. It
can be extremely convenient to practice out of one’s home, and it can be
beneficial for patients to see that their doctor is a “real person.” There are
also significant tax advantages to having a home office; a portion of your
mortgage, your phone line, snow removal, and even toilet paper and so
forth, can be claimed as business expenses. Speak to an accountant and/or
The Psychiatric Office ❚ 41
to a psychiatrist with a home office to learn about the specific tax regula-
tions regarding a home office. There are also disadvantages to having a
home office, particularly when you are first starting out. In the early stages
of practice, many different types of patients will likely be coming through.
You may not feel comfortable having patients with psychosis or severe
personality disorders coming to a home office. Having a home office also
requires psychological flexibility and comfort with being exposed. Estab-
lishing a practice after residency is a difficult endeavor; having a home office
might be an added stress in an already stressful time. It is often better to get
established for a while before undertaking a home office.
Sharing space with another psychiatrist is also a possibility. In getting
to know the psychiatric community, you will often find that other psychia-
trists have office space they would like to share or sublease. You can also
share space with psychologists. Sharing space is usually less expensive than
solo occupancy, but you have to deal the variables involved in having a
“roommate.” It can be nice to have someone to talk to and discuss cases
with, but it can also be difficult if you do not get along with the other per-
son or persons. Sharing space can be in the form of having your own office
in a suite of offices or actually sharing an office, one person using the office
when the other is not there. Although some don’t mind sharing an office,
it is generally more satisfying and comfortable to have space that you can
call your own. It will help you feel settled and enhance your sense of recep-
tivity, which is important when listening to patients.
The above options for office space and their advantages and disadvan-
tages are summarized in Table 4–1.
After you have found space, you need to formalize the acquisition
through execution of a lease. Most commercial space is leased for periods
of time somewhat longer than the usual 1-year lease of residential spaces.
It is often helpful to have an attorney review the lease agreement before
signing. Often, attorneys can discern ways in which the lease might be
worded to be more favorable to the tenant. Common difficulties arise in
delineating responsibility for the physical space. Who is responsible for
what in the event something breaks or malfunctions? What is reasonable
wear and tear, as opposed to damage, to carpet, walls, and such? It should
be clearly established who is responsible for payment of utilities. If the
landlord is paying utilities, is there an escalation clause that the landlord
can add on to your bill? It should be specified that the landlord is not per-
mitted to enter the office without your permission and notification, unless
there is an emergency such as fire or flood. You should establish a time
frame within which the landlord is responsible to respond to requests from
you. For example, if the toilet is broken, the landlord should be responsible
for having it fixed within a reasonable period of time, say 24 to 48 hours.
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Title: History of Central America, Volume 3, 1801-1887
Author: Hubert Howe Bancroft
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*** START OF THE PROJECT GUTENBERG EBOOK HISTORY OF

CENTRAL AMERICA, VOLUME 3, 1801-1887 ***
Transcriber's Note:
Inconsistent hyphenation and spelling in the original

document have been preserved. Obvious typographical
errors have been corrected.
In some cases, Bancroft uses both "u" and "v" to

spell an author's name, e.g. Vetancurt and Vetancvrt.
Other archaic letter substitutions include "b" for "v"

and "i" for "y" and vice versa. These have been left as
printed.
Possible printer's errors include:
On page 5, córtes extraordinary should possibly be

córtes extraordinarias.
On page 149, Patsun should possibly be Patzún.
On page 270, quarters should possibly be halves.
On page 387 repeated should possibly be repealed.
On page 652, 1855-5 appears to be an error.
Joaquin Eufracio Guzman should possibly be Joaquin

Eufrasio Guzman.
Joaquin Eustacio Guzman should possibly be Joaquin

Eufrasio Guzman.
The index reference to "Atrato River" wasn't found.
The index reference to "Montaiglon, M. de, works

of," wasn't found.
Possible alternate spellings or printers errors include:
Jutecalpa and Jutigalpa
Tempsky and Tempski
Blazquez and Blasquez
Savana and Sabana
Sutiaba and Subtiaba
Pontaz and Pontaza
Mourgeon and Murgeon
Iztapan and Iztapam
Serapiqui, Sesapiqui, Sarapiqui River
Carataska and Caratasca
Gualcince and Gualcinse
Nandaime, Nandayme, and Nandaimé
mosquitoes and musquitoes
Cuzcatlan and Cuscatlan
Granadans and Granadians

Chimilapa and Chimalapa
Fitzroy and Fitz-Roy
Victor and Víctor
Jil and Gil
Carlos and Cárlos
Quiroz and Quiróz
Angel and Ángel
Vijil and Vigil
Jerardo and Gerardo
Italics in the footnote citations were inconsistently

applied by the typesetter.
Accents and other diacritics are inconsistently used.
This volume contains references to the previous

seven volumes of this work. They can be found at:
Volume 1:
http://www.gutenberg.org/files/41070/41070-
h/41070-h.htm
Volume 2:
h/42808-h.htm
Volume 3:
h/43123-h.htm
Volume 4:
h/44104-h.htm
Volume 5:
h/45268-h.htm
Volume 6 (Volume 1 of the History of Central

America):
h/58658-h.htm
Volume 7 (Volume 2 of the History of Central

America):
h/58669-h.htm
THE WORKS
OF
HUBERT HOWE BANCROFT.
VOLUME VIII.
HISTORY OF CENTRAL AMERICA.
Vol. III. 1801-1887.
SAN FRANCISCO:
THE HISTORY COMPANY, PUBLISHERS.
1887.
Entered according to Act of Congress in the Year 1887, by
HUBERT H. BANCROFT,
In the Office of the Librarian of Congress, at Washington.
All Rights Reserved.

CONTENTS OF THIS VOLUME.
CHAPTER I.
LAST DAYS OF SPANISH RULE.
1801-1818.
PAGE
Popular Feeling in Central America—Effect of
Events in Spain—Recognition of American
Equality—Representation in the Spanish Córtes
—Delusive Reforms—End of Saravia's Rule—
President José Bustamante—His Despotic
Course—Demands in the Córtes—Constitutional
Guarantees—Official Hostility—Campaign in
Oajaca—Revolutionary Movements in Salvador
—War in Nicaragua—Conspiracy in Guatemala—
Treatment of the Insurgents—Disrespect to the
Diputacion—The Constitution Revoked—Royal 1
Decrees
CHAPTER II.
INDEPENDENCE ACHIEVED.
1818-1821.
President Cárlos Urrutia—His Liberal Views— 23
Colombian Assaults—Spanish Constitution
Restored—The Gazistas, or Bacos—The Cacos—
José del Valle—Pedro Molina—Liberal
Institutions—Extent of the Political Government
—Ecclesiastical Administration—Work of
American Deputies—Party Excitement in
Guatemala—Urrutia Delegates his Powers—
Substitute President Gavino Gainza—Chiapas
and her Government—She Secedes from Spain
and Joins the Mexican Empire—Guatemala
Declares for Independence—Junta Gubernativa
—Convocation of a Congress
CHAPTER III.
UNION WITH MEXICO.
1821-1822.
First Acts of Guatemalan Rulers—Intrigues of
Parties—Their Evil Consequences—Gainza's
Intrigues—Independence in the Other Provinces
—Rewards to Gainza—Troubles in Salvador—
Dissensions in Honduras—Local Squabbles in
Nicaragua—Predilection for Imperialism—Costa
Rica Neutral—Condition of Various Sections—
Seceding Districts of Guatemala—Perplexities of
the Junta Consultiva—Iturbide's Devices—
Military Pressure—His Proposals Accepted—
Illegal Annexation—Protests and Resistance— 42
War Begins
CHAPTER IV.
CENTRAL AMERICAN CONFEDERATION.
1822-1825.
Secession from Mexico—Arzú's Campaign— 60
Prevarication of Salvador—Filisola's Victory—His
Subsequent Course—Liberal Triumph in Costa
Rica—Honduras Favors Union—National
Independence Secured—Labors to Organize a
Nation—The Constituent Assembly—Provincias
Unidas del Centro de América—Abolition of
African Slavery—Provisional Government—
Moderados or Serviles—Liberales or Fiebres—
Principles and Aims of Parties—Mexican Forces
Retire—Seditions Begin—Salvadoran Force in
Guatemala—Confederacion de Centro América
—Fundamental Law—Finances—Adjournment of
the Constituent Assembly
CHAPTER V.
CONSTITUTIONAL GOVERNMENT.
1825-1830.
General Elections—Meeting of the First Congress
—Manuel José Arce, First President of the
Republic—Foreign Relations—Arce's
Prevarications—Conflict with Guatemala—Party
Bickerings—Liberals Quarrel with Arce—He
Joins their Opponents—Bitterness Engendered
—President versus Guatemalan Rulers—Arrest
of Jefe Juan Barrundia—Riots at Quezaltenango
—Murder of Vice-jefe Cirilo Flores—Arce as
Dictator in Guatemala—War against Salvador—
Arce Defeated—He Gives up the Presidency,
and Cannot Recover It—Bloody War of 1826-9
—Morazan the Victor—José Francisco
Barrundia, Acting President—Liberal Measures— 79
Peace Restored—Spanish Schemes
CHAPTER VI.
CIVIL WAR.
1829-1838.
Revolution in Honduras—Conservatives Invade 108
the State—Second General Elections—Francisco
Morazan Chosen President—Plots of the Serviles
—Arce's Invasion from Mexico—Occupation of
Honduras Ports by Exiled Rebels—Spanish Flag
Hoisted in Omoa, and Aid from Cuba—
Salvadoran Authorities in Rebellion—Third
General Elections—Morazan Reëlected—Failure
of Colonization Plans—Ravages of Cholera—
Indian Revolt under Carrera—His Early Life
CHAPTER VII.
DISSOLUTION OF THE REPUBLIC.
1837-1840.
Campaign against Carrera—Several Departments
of Guatemala in Rebellion—Jefe Galvez
Deposed—Carrera Takes Guatemala—Murder of
Salazar—Carrera Accepts Money to Leave the
City—Dictatorship Offered Morazan by the
Aristocrats and Refused—Carrera's Second
Rebellion—The Republic in Peril—Morazan's
Efforts to Save It—Nicaragua and Honduras
Forces Invade Salvador—Morazan Defeats
Them—His Retreat to San Salvador—He
Embarks—Is Refused Hospitality in Costa Rica—
Goes to South America—The Republic is Dead— 127
Salvador at the Mercy of Carrera
CHAPTER VIII.
GUATEMALA AND HONDURAS.
1824-1840.
State Government of Guatemala—Barrundia's 145
Radicalism—His Overthrow—Vice-jefe Flores
Assassinated in Quezaltenango—Downfall of
the Liberals in Guatemala—Aristocratic Leaders
Exiled—Jefe Molina—His Differences,
Impeachment, and Acquittals—Rivera Cabezas'
Reforms—Earthquakes—Galvez' Rule and its
Benefits—Party Opposition to Him—Indian
Outbreaks—Carrera Captures Guatemala—
Galvez Resigns—Subsequent Rule of the
Aristocrats—Guatemala again Independent—
Honduras' State Government—Jefe Dionisio
Herrera—Early Dissensions—Comayagua
Assaulted by Rebels—Morazan in the Field—
Honduras Secedes from the Central American
Confederation—Federalism Rooted out of her
Territory
CHAPTER IX.
SALVADOR, NICARAGUA, AND COSTA RICA.
1824-1840.
Salvador State Government—Liberals Overthrown
—Secession from the Union—San Salvador as
the Federal Seat of Government—Guatemala
Imposes her Will—Jefe Cañas and Comandante
Malespin—Nicaragua's Early Troubles—Siege
and Bombardment of Leon—Organization of
State Government—Dissensions and Warfare—
Eruption of Cosigüina—Secession from the
Confederation—Costa Rica as a Confederated
State—Juan Mora's Administration—Towns'
Bickerings Settled—Braulio Carrillo's Rule—Final
Secession from the Central American Republic— 165
Prosperity of the State
CHAPTER X.
DISSOLUTION OF THE UNION.
1839-1852.
Interstate Dissensions—Pacto de Chinandega— 186
Confederacion Centro Americana—Supremo
Delegado Chamorro—Hostility of Guatemala
and British Officials—Arce Invades Salvador—
War of the Confederacy against Guatemala—
Helplessness of Chamorro—End of the Pacto de
Chinandega—Condition of the States—Ferrera's
Bad Faith—Salvador and Honduras against
Nicaragua—Horrors of Leon—Vice-president
Joaquin E. Guzman—Honduras and Salvador at
War—Guardiola's Vandalism—Malespin
Overthrown—Renewed Efforts to Confederate—
Guatemala an Independent Republic—Costa
Rica Follows—Salvador, Nicaragua, and
Honduras a Confederacy—Its Short Life—
Further Unsuccessful Attempts
CHAPTER XI.
REPUBLIC OF COSTA RICA.
1841-1856.
Rule of Carrillo Continued—Plots for its Overthrow
—Invasion of Morazan—Change of Government
—Morazan's Policy—Opposition—Revolts—
Morazan's Defeat and Death—Satisfaction of
the Oligarchs—Measures of the Victors—New
Constitution—Subsequent Amendments—
Sedition—Castro's Administration—Costa Rica
Declared a Republic—Recognition by Spain—
Relations with Other Powers—Boundary
Questions with Nicaragua and Colombia—
President Juan Rafael Mora—His Repressive 215
Measures
CHAPTER XII.
REPUBLIC OF NICARAGUA.
1838-1855.
State Government—Director Buitrago's 238
Conservatism—British Aggression—Director
Sandoval's Rule—Internal Troubles—Guerrero's
Administration—The Mosquito Kingdom—Its
Origin and History—Bubbles—British
Pretensions—Seizure of San Juan del Norte—
Diplomatic Complications—Clayton-Bulwer
Treaty—Nicaragua Recovers her Own—
Relations with Foreign Powers—An American
War Ship Bombards San Juan del Norte—
Pineda's Government—Establishment of the
Republic—Party Dissensions—Legitimists versus
Democrats—Chamorro and Castellon—Civil War
—Death of Chamorro—Estrada Succeeds Him
CHAPTER XIII.
REPUBLIC OF GUATEMALA.
1840-1865.
President Rivera Paz—Carrera's Course—
Pretended Sedition—Dissolution of the
Assembly—A Consejo Constituyente Created—
Carrera Becomes President—Attempt against
his Life—Revolt of Monterrosa—Carrera's
Despotism—The Republic Established—
Relations with Other Powers—Revolution of the
Mountain—Constituent Assembly Convened—
Carrera's Forced Resignation and Exile—Liberals
Triumphant—Their Squabbles and
Disintegration—The Moderado Party—
Revolution of Los Altos—Intrigues of the
Serviles—Presidencies of Martinez and Escobar
—Causes of their Resignations—Paredes—Recall
of Carrera—Deeds of Vengeance—Carrera again 264
President—Partial Restoration of Peace
CHAPTER XIV.
REPUBLIC OF SALVADOR.
1839-1865.
Malespin's Acts—Lindo's Coup d'Etat and Deposal 285
—Jefe Guzman—Revolt at Santa Ana—President
Aguilar—The Bishop Expelled—Viteri's Alliance
with Malespin and Honduran Oligarchs—
President Vasconcelos—British Hostilities—
Salvador's Relations with Foreign Powers—San
Martin's Administration—Destruction of San
Salvador—President Campo—Campaign against
Walker in Nicaragua—Establishment of the
Republic—Santin's Overthrow—Presidency of
Gerardo Barrios—War of Salvador and
Honduras against Guatemala and Nicaragua—
The Latter Victorious—Barrios' Flight—
Restoration of Peace—Dueñas as President—
Barrios' Subsequent Return—His Capture and
Surrender by Nicaragua—His Execution in San
Salvador
CHAPTER XV.
REPUBLIC OF HONDURAS.
1840-1865.
President Ferrera—Revolutionary Movements—
Political Executions—Presidency of Juan Lindo—
New Constitution—Lindo Overthrown—Belize—
Honduras' Troubles with Great Britain—British
Occupation of Tiger Island—Bombardment of
Omoa—Bay Islands—President Cabañas—War
with Guatemala—Guardiola's Assassination—
Provisional Rules of Castellanos and Montes—
Alliance with Barrios—Unsuccessful War with
Guatemala and Nicaragua—Montes Deposed—
Establishment of the Republic—José M. Medina
Chosen President—Amendment of the 309
Constitution
CHAPTER XVI.
WALKER'S CAMPAIGN IN NICARAGUA.
1855-1856.
Kinney's Expedition—William Walker Joins the 327
Democrats—Failure of his Expedition to Rivas—
Cholera Decimates the Legitimists at Managua
—Death of Muñoz—Walker's Victories at La
Vírgen and Granada—Execution of Minister
Mayorga—Walker's Convention with Corral—
Provisional Government Organized—President
Patricio Rivas—Commander of the Forces,
Walker—Minister of War Corral Put to Death for
Treason—Recognition by Salvador and
Honduras—Seizure of the Transit Company's
Steamers—Costa Ricans on the War-path—
Havoc of Cholera
CHAPTER XVII.
END OF FILIBUSTERING IN CENTRAL AMERICA.
1856-1867.
Recognition of President Rivas by the United
States—Walker's Hostile Attitude—Flight of
Rivas—Walker Makes Himself President—
Alliance against Him—Death of Estrada—The
Legitimists Accept Rivas—Costa Ricans and
Nicaraguans in Rivas—Destruction of Granada—
It is Occupied by Allied Forces—Walker
Reoccupies Rivas—Where He is Besieged—
Successes of the Costa Ricans—Failure of
Lockridge's Expedition—Surrender of Walker—
War of Nicaragua and Costa Rica—Commodore
Paulding and Walker's Second Attempt—
Walker's Invasion of Honduras, Capture, and
Execution—Government Reorganized— 347
President Martinez' Administrations
CHAPTER XVIII.
POLITICAL EVENTS IN COSTA RICA.
1856-1886.
Rewards to Walker's Conquerors—Reëlection of 371
Mora—His Downfall and Exile—His Return,
Capture, and Execution—Montealegre's
Administration—Violence of Parties—
Compromise on Jesus Jimenez—His Peaceful
Rule—President José M. Castro—Charges
against Him—His Overthrow—Several New
Constitutions—Jimenez again President—His
Arbitrary Acts—How He was Deposed—
President Carranza—Other Temporary Rulers—
President Guardia's Despotism—Failure of his
Warlike Plans—His Death—Administration of
Próspero Fernandez—Preparations to Defend
Independence—His Sudden Death—Bernardo
Soto's Peaceful Rule
CHAPTER XIX.
DEMOCRATIC INSTITUTIONS IN SALVADOR.
1865-1885.
Rule of President Dueñas—His Conservatism—
Quarrel with Honduras—The Latter Allied with
Salvadoran Liberals—Battle of Santa Ana—
Dueñas Deposed—His Impeachment, Release,
and Temporary Exile—Santiago Gonzalez
Provisional President—Gonzalez Elected Chief
Magistrate—Guatemala and Salvador at War
with Honduras—Murder of Vice-president
Mendez—Earthquakes—President Valle—Trouble
with Guatemala—Exeunt Valle and Gonzalez—
Zaldívar's Long Rule—Constitutional Changes—
Alliance with Nicaragua and Costa Rica—
Resistance to Barrios' Plan of Conquest—
Salvador Victorious—Restored Peace—Zaldívar
Eliminated—Revolution—F. Menendez Made 392
President
CHAPTER XX.
DEMOCRACY RESTORED IN GUATEMALA.
1865-1873.
President Cerna's Rule—Partial Revolts—Liberals
in the Assembly—Cerna's Reëlection—Riots in
the Capital—Zavala's Course—Cruz' Rebellion,
Defeat, and Death—Arrests of Liberals—
Moderation of the Government—Revolution of
García Granados and Barrios—Plan of Patzicia—
Cerna Defeated and Overthrown—Granados as
Presidente Provisorio—Seditious Movements
Quelled—Abolition of Priestly Privileges—
Prelates, Jesuits, and Capuchins Expelled—War
with Honduras—Barrios as Substitute President
—His Severity—Elections—Barrios Chosen 413
Constitutional President
CHAPTER XXI.
RENEWED EFFORTS FOR CENTRAL AMERICAN UNITY.
1873-1885.
President Barrios of Guatemala—End of
Reactionary War—Guatemalan Progress—War
with Salvador and Honduras—Barrios'
Successes and Generosity to the Vanquished—
Constitutional Régime in Guatemala—Barrios'
Reëlections—His Visit to the United States—
Peaceful Effort to Unite Central America—Resort
to Arms—Alliance of Guatemala and Honduras
—Barrios Attacks Salvador—His Defeat and
Death—His Plan Abandoned—M. L. Barillas,
Provisional President of Guatemala—Restoration 431
of Peace
CHAPTER XXII.
HONDURAS AFFAIRS.
1865-1886.
National Flag and Escutcheon—Order of Santa 453
Rosa—Medina's Long Rule—His Differences with
Dueñas, and Triumph—War with Salvador and
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