Concerned about Psychiatry falling by the wayside

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We have PAs in our neurosurgery department. They can do quite a bit of procedures. After all it is only brain surgery, not rocket science.
…or rocket surgery! :D

(as my ex-NASA physicist friend was fond of saying)

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I'm concerned--NAY TERRIFIED that as NP's and PA's soak up the family care needs, they'll drive family docs, internists, and psychiatrists out of business.

The NP 'takeover' is not a result of cost cutting, it is a result of a severe shortage that has manifested itself in hordes of mid-level practitioners that have no desire to further the discipline, but can adequately plug the hole. Somewhere along this process we have exposed to the country that the work we do is, for the most part, overpriced. Let's not kid ourselves, this is the real argument for mid-levels, and this is why we fear them. Despite this reality check, we continue to have the luxury of a guaranteed six-figure salary waiting for us at the end of residency. With the cost of medical school what it is, this continues to be a pretty safe bet as a long-term investment.

But all of this is a separate argument. For even if every single psychiatrist in America took a pay cut tomorrow, and promised to work for $1 less per hour than any nurse practitioner, it still wouldn't have any impact on the real, crisis level, shortage in mental health workers and the high, high demand for psychiatrists.

If you really want to be TERRIFIED, go talk to the radiologist who is on his second fellowship, debating moving to South Dakota, and has no idea what an NP is...there is no perfect specialty.
 
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The NP 'takeover' is not a result of cost cutting, it is a result of a severe shortage that has manifested itself in hordes of mid-level practitioners that have no desire to further the discipline, but can adequately plug the hole. Somewhere along this process we have exposed to the country that the work we do is, for the most part, overpriced. Let's not kid ourselves, this is the real argument for mid-levels, and this is why we fear them. Despite this reality check, we continue to have the luxury of a guaranteed six-figure salary waiting for us at the end of residency. With the cost of medical school what it is, this continues to be a pretty safe bet as a long-term investment.

.

Everybody, put your fingertips together and chant "Hmmmm..." Then read the above 5 times. Everything will be fine.

If you don't believe me, go to a cocktail party without doctors and see how much sympathy you can generate over the future of psychiatry incomes.
 
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Getting at least 3 calls and emails a day right now from recruiters with varying degrees of urgency and desperation. All my grads are spoken for, and the G3s are already interviewing.
 
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Recruiter: “Hay training director, tell your residents I have a lot of openings if they are interested in some good jobs right in your area.”
Training Director: “So do we.”
 
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Getting at least 3 calls and emails a day right now from recruiters with varying degrees of urgency and desperation. All my grads are spoken for, and the G3s are already interviewing.

:thumbup:
Hope you (or you residents) manage to get some fancy dinners off these recruiters
 
At the rate cardiology reimbursements are getting cut, we will have cardiology NPs taking over there too.

"Here, let's hook you up to this EKG. That looks like an st-elevation right there. See that line?"
 
Recruiter: “Hay training director, tell your residents I have a lot of openings if they are interested in some good jobs right in your area.”
Training Director: “So do we.”

the problem is though that the starting junior faculty positions don't pay well. At least for positions that are truly academic positions(even fully clinical) in a real academic hospital environment.

There are plenty of jobs in community systems which make up large components of a program that pay well above standard academic salaries, but these are academic positions in name only in some ways. There is one right now at AltaPointe in Mobile(South Alabama program) which starts at around 220, but that's a heck of a lot different environment(not saying it's better or worse) than the person who takes a job at say University of Florida for 160k....
 
the problem is though that the starting junior faculty positions don't pay well. At least for positions that are truly academic positions(even fully clinical) in a real academic hospital environment.

There are plenty of jobs in community systems which make up large components of a program that pay well above standard academic salaries, but these are academic positions in name only in some ways. There is one right now at AltaPointe in Mobile(South Alabama program) which starts at around 220, but that's a heck of a lot different environment(not saying it's better or worse) than the person who takes a job at say University of Florida for 160k....

Truer words were never spoken.

Most graduates out earn their teachers starting at midnight on July 1st. You have to enjoy teaching enough to justify the difference. Maybe this is best. Could you imagine what it would be like if teachers were in it for the high pay, but had no interest or inclination towards teaching?
 
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the problem is though that the starting junior faculty positions don't pay well. At least for positions that are truly academic positions(even fully clinical) in a real academic hospital environment....There is one right now at AltaPointe in Mobile(South Alabama program) which starts at around 220, but that's a heck of a lot different environment(not saying it's better or worse) than the person who takes a job at say University of Florida for 160k....

"Ugh, I'm only earning $160,000 a year at my prestigious academic position in Florida."

So tragic that you, as an individual, will only out-earn 96% of the rest of Florida's combined households...I bet the four households out of one hundred will pity you.

Take a look - http://www.nytimes.com/interactive/2012/01/15/business/one-percent-map.html
 
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"Ugh, I'm only earning $160,000 a year at my prestigious academic position in Florida."

So tragic that you, as an individual, will only out-earn 96% of the rest of Florida's combined households...I bet the four households out of one hundred will pity you.

Take a look - http://www.nytimes.com/interactive/2012/01/15/business/one-percent-map.html

well many americans are going to owe 100k or more in student loans.....some even 125k+ I've heard. And only a very small portion of that is tax deductible(like 2500 or 3000 of the interest per year, maybe not even that above certain income levels not sure)

then that also comes with a non-compete most likely....so knock any extra earning potential(which other jobs in other fields that pay less would have) out.
 
Truer words were never spoken.

Most graduates out earn their teachers starting at midnight on July 1st. You have to enjoy teaching enough to justify the difference. Maybe this is best. Could you imagine what it would be like if teachers were in it for the high pay, but had no interest or inclination towards teaching?

Many of our senior residents(and 1 pgy3) outearn many faculty(and not just junior faculty) right now by moonlighting a lot.
 
well many americans are going to owe 100k or more in student loans.....some even 125k+ I've heard. And only a very small portion of that is tax deductible(like 2500 or 3000 of the interest per year, maybe not even that above certain income levels not sure)

then that also comes with a non-compete most likely....so knock any extra earning potential(which other jobs in other fields that pay less would have) out.
No student loans are deductable.
 
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well many americans are going to owe 100k or more in student loans.....some even 125k+ I've heard.

I understand your point re: loans, but if you are earning $160k, pulling out 35% of your pretax income to cover loans for ten straight years would still land you in the top ten percent of earners for the duration of your repayment. What exactly is your argument? That a person could not reasonably live on the equivalent of $104,000 while they pay down their loans?

EDIT: the above scenario assumes a person has $300,000 in loans. And with some quick math ends up paying 364,000 over 10 years to cover it, using 35% or $56,000 pre-tax per year. That is a WORST CASE scenario
 
I understand your point re: loans, but if you are earning $160k, pulling out 35% of your pretax income to cover loans for ten straight years would still land you in the top ten percent of earners for the duration of your repayment. What exactly is your argument? That a person could not reasonably live on the equivalent of $104,000 while they pay down their loans?

EDIT: the above scenario assumes a person has $300,000 in loans. And with some quick math ends up paying 364,000 over 10 years to cover it, using 35% or $56,000 pre-tax per year. That is a WORST CASE scenario

well for starters you don't pay loans based on pretax income.....it's only useful to look at post-tax income.

second, 104k is not a very good salary
 
well for starters you don't pay loans based on pretax income.....it's only useful to look at post-tax income.

second, 104k is not a very good salary

Actually it is great to use pre-tax income because you can then translate the shortfall to your relative salary, controlling for the difference in taxable income. In the above example, the payer uses $56k of pre tax income, which is $36k towards loans each year.

Not a good salary compared to what? A dermatologist, yes. The 90% of households in Florida who earn less than that? NO.
 
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above 60k MAGI the deduction is phased out till completely at 75k
 
@vistaril ... Do you consider 100k/year with no student debt a good salary?

i think that is a great salary, but i'd probably be able to hit that if i had continued working at my office job so i guess i wouldn't be satisfied.
 
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vistaril reminds me of Sarah Palin. text salad instead of a word salad.
 
Psychiatry is not popular amongst MDs and the same is the case for NPs.

Less than 2-3% of graduating NPs select psychiatry as a specialty.

Is this because Americans value a macho, extroverted, never show weakness or talk about your feelings mentality?
 
Is this because Americans value a macho, extroverted, never show weakness or talk about your feelings mentality?

the biggest reasons why psychiatry is so noncompetitive amongst medical students are:

1) doesn't seem very medical/want to be a 'real doctor'
2) doesn't pay very well compared to other specialties
3) doesn't impress others(in and out of medicine) very much

All the other reasons are trivial/secondary compared to those. And Im not saying they are 'good' reasons or not. But that's why.
 
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Vistaril, what are your thoughts on the future of psychiatry subspecialties, such as child psych?
 
Vistaril, what are your thoughts on the future of psychiatry subspecialties, such as child psych?

I'm not a child psychiatrist, but just as a casual observer it appears that many of the same problems rampant in adult/general psychiatry are even worse in child psychiatry. Even more sketchy diagnostic criteria, even more polypharmacy, even more haphazard practicing, even more questionable benefits for some of the patients,etc.....and it seems that an even smaller number of patients have appropriate resources.

With even field(not just in health care or mental health) just because there is a percieved shortage and a percieved demand doesn't mean the future is good in a field. There is a lot of demand for speed of light transportation and a shortage of people that can safely pilot such crafts that travel at the speed of light- doesn't mean the future is good for such jobs:) That's possibly an important point to remember for psychiatry in general, but especially child psych.
 
From my short view into child psych, there were many instances where the attending would decrease medications that other pediatricians had prescribed. But that is a very small sample, and I'm sure child psych is by no means a perfect field. I imagine it would be highly satisfying that you can (even if it's rarely) make a real tangible difference in the little ones.
There is a "threat" we hear all around SDN of the future of midlevels and primary care (and anesthesia), however, to my knowledge, psych NPs do not have training in C&A psych, and therefore would likely not be competing, if you will, for jobs.
 
the biggest reasons why psychiatry is so noncompetitive amongst medical students are:

1) doesn't seem very medical/want to be a 'real doctor'
2) doesn't pay very well compared to other specialties
3) doesn't impress others(in and out of medicine) very much

All the other reasons are trivial/secondary compared to those. And Im not saying they are 'good' reasons or not. But that's why.
I think psychiatry will evolve eventually its just a matter of time. you don't know for the future they might consider combining psychiatry and neurology into brainology.
 
One of the most disgruntled doctors I've met was a neurosurgeon in New York who called himself the gold card in a pissed off way. After a procedure he would say the gold card's swiped. He always said this so one day I asked him what he meant. He said the hospital is making too much off him and should pay him more. He felt ripped off for the work he was doing, and he was at a famous hospital in New York making - to a psychiatrist - good money. Yet he walked around calling himself the gold card because the hospital took so much of a percentage from his surgeries. I don't see psychiatrists walking around hospitals feeling stolen from. Personally, I'd rather be in the 3% bracket or earners feeling well-compensated instead of the 1% feeling ripped off.

Someone more disgruntled than either myself or Vistaril? Wow, put me in touch with this guy! I'll buy him a drink!
 
Someone more disgruntled than either myself or Vistaril? Wow, put me in touch with this guy! I'll buy him a drink!

well I think there are different kinds of disgruntled.......his type of disgruntled is far different than our type of disgruntled. I don't think for example that when he evacuates an actual brain bleed and saves a life right there that he wonders about the evidence/effectiveness behind what he just did as compared to when some psychiatrist somewhere switches a borderline from Tegretol to Seroquel.
 
No. You don't know. Because you don't deal with facts. All you do is laugh using "lol" to anything you disagree with. Knowledge is based on facts. You don't deal with facts therefore you don't have knowledge. How the hell you made it to med school is beyond me. My challenge to you is to come back with facts. That's right, go look stuff up and post us your links and references. ALL OF US are tired of you making statements with no proof. Start backing up your claims. You're not fooling ANYONE on these forums. Even people from other specialties know your reputation. Want to start convincing us of anything, start giving references and facts.

I'm not annoyed by Vistaril. Sometimes he says things I don't agree with, but so do a lot of people. It's also not really fair to demand a level of accuracy from Vistaril that you don't demand of everyone else on the forum. Plenty of people post inaccurate things here. That's what the internet is all about - spreading misinformation. I actually read a deadpan tone in a lot of his posts, so I don't take the negativity too much to heart, and in fact they often make me laugh. Plus I'm really negative too. One of the great things about the internet is that you can find other people with interests similar to your own, halfway across the country or even the world sometimes.
 
Of course you back down from the challenge, because you know you'll lose your entire house of cards propaganda once you're forced to base your claims on facts. It's like asking the government of the People's Republic of China to please start using sound evidence for their decisions. They would laugh and say "I'll politely refuse..." and go about ruling with an iron fist.

You don't need to use China as an example. The US will do. Wow, this is a fun thread!
 
well I think there are different kinds of disgruntled.......his type of disgruntled is far different than our type of disgruntled. I don't think for example that when he evacuates an actual brain bleed and saves a life right there that he wonders about the evidence/effectiveness behind what he just did as compared to when some psychiatrist somewhere switches a borderline from Tegretol to Seroquel.

Why switch when they can just take both?
 
Why switch when they can just take both?

Well supposedly there is an interaction between the two that would reduce the plasma level of seroquel by some unknown amt(in addition to altering a metabolite of tegretol) so you have to base your dosing on that. Of course like most things in psychiatry it comes down to a rule of thirds on the matter:

-a third of psychiatrists in practice either don't know or don't care and don't adjust their dosing
-a third of psychiatrists just guess at what dose of seroquel they want and guess at the adjustment for each pt
-a third of psychiatrists just avoid the combination entirely

Not sure which is right approach really.

Of course of an even better possibility to your suggestion would be why not just take both....and add adderall.
 
Well supposedly there is an interaction between the two that would reduce the plasma level of seroquel by some unknown amt(in addition to altering a metabolite of tegretol) so you have to base your dosing on that. Of course like most things in psychiatry it comes down to a rule of thirds on the matter:

-a third of psychiatrists in practice either don't know or don't care and don't adjust their dosing
-a third of psychiatrists just guess at what dose of seroquel they want and guess at the adjustment for each pt
-a third of psychiatrists just avoid the combination entirely

Not sure which is right approach really.

Of course of an even better possibility to your suggestion would be why not just take both....and add adderall.

I think you should add adderall and klonopin.

I have an idea for a blockbuster miracle drug. I will take small doses of all the existing psych meds and combine them into one extended release non-breakable capsule, and call it Psyquel.
 
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"Ugh, I'm only earning $160,000 a year at my prestigious academic position in Florida."

So tragic that you, as an individual, will only out-earn 96% of the rest of Florida's combined households...I bet the four households out of one hundred will pity you.

Take a look - http://www.nytimes.com/interactive/2012/01/15/business/one-percent-map.html

73% of adults in florida (24 or older) haven't even attained a bachelor's degree (and this in the time of online and for-profit colleges: no liberal arts or sciences req'd). So at least compare your income to other people with professional degrees. Neither a JD nor MBA requires the time and effort of an MD+residency but you'll at least start to get to a semi-meaningful statistic. (Unless you're some sort of radical socialist or self-hating doctor.)
 
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From my short view into child psych, there were many instances where the attending would decrease medications that other pediatricians had prescribed. But that is a very small sample, and I'm sure child psych is by no means a perfect field. I imagine it would be highly satisfying that you can (even if it's rarely) make a real tangible difference in the little ones.
There is a "threat" we hear all around SDN of the future of midlevels and primary care (and anesthesia), however, to my knowledge, psych NPs do not have training in C&A psych, and therefore would likely not be competing, if you will, for jobs.

All psych NPs from here on out are now licensed with a 'lifespan' license, which includes seeing and treating kiddos.
 
All psych NPs from here on out are now licensed with a 'lifespan' license, which includes seeing and treating kiddos.

He said "do not have training in" and "therefore would likely not be". Obviously all Psychiatrists are licensed to treat children too. But even with years of residency (which includes some C/A) and work experience most wouldn't do it without also doing a C/A fellowship (there was a thread about this a while back- it's tempting given the sometimes higher pay rate).

If you're saying that nurse practitioners are more aggressive about doing things outside their education/training...ok...agreed...pretty much see instances of them doing that in every medical field.
 
He said "do not have training in" and "therefore would likely not be". Obviously all Psychiatrists are licensed to treat children too. But even with years of residency (which includes some C/A) and work experience most wouldn't do it without also doing a C/A fellowship (there was a thread about this a while back- it's tempting given the sometimes higher pay rate).
.

you'll see when you get out in the real world(in most settings) that these lines are a lot more blurred.....most adult psychiatrists in most settings/locales don't see kids because they don't want to. Seeing yet another kid who won't stop hitting his siblings in 15 minute blocks with their overwhelmed mom present isn't most peoples idea of a good time. And since so many kids with these sorts of behavior problems have Medicaid, you'll find that a lot of the people who will see them(for the e/m portion of things) will fall into 3 categories:
-psych nps
-adult psychiatrists whose employer or agency is forcing them to see a certain number of kids
-child psychiatrists

Now there are plenty of exceptions. Obviously academic centers for faculty positions are going to hire C/A trained people. And psych practices that are almost 100% C/A and are cash pay with longer appts and more patient centered care will usually be headed by a C/A person(simply because the parents have more choices)

But those two settings, in reality, are not where most of these kids are seen. When I was in residency I looked at the total number of weekly C/A outpt visits that came through the university in the C/A clinic(staffed by C/A people). Then compared it to the volume of visits that come through one of the community mental health agencies that sees a lot of medicaid(not C/A people). It was 5/1 based on volume in favor of the non-academic cmhc. So someone other than BE/BC child people are seeing those kids......
 
well many americans are going to owe 100k or more in student loans.....some even 125k+ I've heard. And only a very small portion of that is tax deductible(like 2500 or 3000 of the interest per year, maybe not even that above certain income levels not sure)

then that also comes with a non-compete most likely....so knock any extra earning potential(which other jobs in other fields that pay less would have) out.

A lot of people will owe 4-500K.
 
He said "do not have training in" and "therefore would likely not be". Obviously all Psychiatrists are licensed to treat children too. But even with years of residency (which includes some C/A) and work experience most wouldn't do it without also doing a C/A fellowship (there was a thread about this a while back- it's tempting given the sometimes higher pay rate).

If you're saying that nurse practitioners are more aggressive about doing things outside their education/training...ok...agreed...pretty much see instances of them doing that in every medical field.

Uh, psych NPs are required to receive training in child/adolescent psychiatry now since the license recently change to a lifespan one. Before this change, not all psych NPs were licensed to see children. In the past there were different licenses (child psych NP, adult psych NP, etc.) Now there is only one license, which means all students must get clinical training across the lifespan before graduating.
 
Uh, psych NPs are required to receive training in child/adolescent psychiatry now since the license recently change to a lifespan one. Before this change, not all psych NPs were licensed to see children. In the past there were different licenses (child psych NP, adult psych NP, etc.) Now there is only one license, which means all students must get clinical training across the lifespan before graduating.

That's cute. Kind of like medical students who receive training in all fields. Weeee! Ready for work! In like....anything.
 
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That's cute. Kind of like medical students who receive training in all fields. Weeee! Ready for work! In like....anything.
Y
In many settings, a psych np just out of school is going to provide the same level of care as a bc child psych with 25 years experience. That's not because the child psych doesn't know more or have more experience/training(they probably do)....but when you are seeing a kid for meds only(the therapist down the hall is already doing therapy with them and fam regardless) and the kid is the typical bat out of hell who hates the world, hates his family, keeps punching kids in his 6th grade class, killed the neighbors cat, and whatnot....well let's just say the med regimens are going to look pretty darn similar and that is all either is doing anyways.
 
I understand your point re: loans, but if you are earning $160k, pulling out 35% of your pretax income to cover loans for ten straight years would still land you in the top ten percent of earners for the duration of your repayment. What exactly is your argument? That a person could not reasonably live on the equivalent of $104,000 while they pay down their loans?

EDIT: the above scenario assumes a person has $300,000 in loans. And with some quick math ends up paying 364,000 over 10 years to cover it, using 35% or $56,000 pre-tax per year. That is a WORST CASE scenario

The amount that you can deduct for student loans is only a couple of thousand a year.
 
Uh, psych NPs are required to receive training in child/adolescent psychiatry now since the license recently change to a lifespan one. Before this change, not all psych NPs were licensed to see children. In the past there were different licenses (child psych NP, adult psych NP, etc.) Now there is only one license, which means all students must get clinical training across the lifespan before graduating.
Are you really trying to argue this? The beauty of Psych is that it is poorly understood by the public- and they do not have their own ways about managing or recognizing mental illness. They will either seek care or "deal with it". What this means is that the layman will almost always prefer the Psychiatrist. NPs don't want to go into psychiatry. Psych patients don't want to see NPs. To con them for drugs maybe, but not for adequate care.
 
That's cute. Kind of like medical students who receive training in all fields. Weeee! Ready for work! In like....anything.
Well ever since I've been past MSK Orthopedics and Gross Anatomy UL, LL I've been doing total joint reconstruction in back alleys. I thought this was legit.
 
Are you really trying to argue this? The beauty of Psych is that it is poorly understood by the public- and they do not have their own ways about managing or recognizing mental illness. They will either seek care or "deal with it". What this means is that the layman will almost always prefer the Psychiatrist. NPs don't want to go into psychiatry. Psych patients don't want to see NPs. To con them for drugs maybe, but not for adequate care.

What? My statement has nothing to do with any of the 'points' you are making. Someone assumed that NPs do not get training or clinical hours in child psych and do not take jobs in child psychiatry. I was correcting the false assumption regarding psych np training and licensing, nothing more. I certainly was not stating that psych NP training is somehow equivalent to that of child psychiatrists. Your last two statements had me chuckling though, so thanks for the laugh.
 
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