Future of Psychiatry With NPs Practicing Independently

[bltzybltz]

Hi all! MS1 wondering what your takes are on the future of psychiatry. To be honest, it seems like by the time I graduate and complete residency, most staff-type positions (hospital inpatient, clinics, prisons) are going to be staffed by several NPs rather than a psychiatrist. Based on my readings, it seems like the future of psychiatry is private practice, which is cool but I'm not necessarily very entrepreneurial.

Am I wrong to be worried? Are these jobs likely to be available in 7-10 years down the road? Would you recommend against going into psychiatry if I'm worried about finding a job in a typical populated metro area in 7-10 years?

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[liquidshadow22]

you are not wrong to be worried. NPs are being popped out at a rate that is 5-6 x that of a physician and the lawmakers do not have your back. They will continue to advance in independent practice rights. You will always have a job in my opinion, but i think it will cut into the pockets of psychiatrists eventually, and i am sure it is already making a substantial impact even in private practice.

At the end of the day, this issue is all about $$. If you care about this, then go to into a specialized procedural field. - gastroenterology, interventional cardiology, interventional neurology, neurosurgery etc. If you are not as concerned and love psychiatry and cant do the other fields, then stick with it.

 

[WisNeuro]

As in other areas of healthcare, such as therapy, midlevels continue to gain ground. But, it also seems that more people are utilizing MH services, which keeps demand for all high. In terms of the general population, many of them will just see whomever they are assigned or referred to for their healthcare services, unfortunately. But, you'll still have a population that prefers doctoral level providers. I only see doctoral level providers personally, and I only refer out to doctoral level providers for my patients.

 

[FlowRate]

We have a unique and powerful differentiating factor which is 4 years of residency. Those 4 years challenge us to formulate/conceptualize/diagnose our patients and then be able to justify those conceptualizations to hopefully thoughtful and experienced supervisors. That process refines our ability to clarify the root issues, whether diagnostic/phenomenological or psychological/dynamic, which is the bedrock beneath our treatment plans.

This unique differentiator is almost impossible for the average NP or PA to attain. They fill a void doing a hopefully better job than GP's in absorbing the huge demand for mental health services but they are not a replacement for us.

An analogous gap in the rest of the medical world is neurology. The neurological exam is king and being able to do a truly high quality, focused, effective, repeatable, accurate neuro exam takes years of training.

 

[MacDonaldTriad]

You are wrong to be worried. I have answered many of these similar threads, but don't be influenced by chicken little. NPs and PA's intrusions into our field is a symptom of our lack of ability to provide for the need. It is supply and demand and we are rare and well paid. A lot of Mid levels do or jobs poorly, and GPs do most of our work very poorly. We do add value that isn't replaced by mid levels and if you don't see that, you probably don't belong in psychiatry or you are poorly trained. There are poorly trained psychiatrists out in the practicing world, but hopefully they see their limits and so should all of us. I have not been impressed with the judgement of unsupervised NPs. I have also been aware of some NPs that are better than some psychiatrists. It depends on who is teaching/supervising the mid-levels.

 

[deleted1100659]

I am also not worried about this. I would be more worried if i was a PCP but the demand for MH is so high seems unlikely well get phased out anytime soon. Seems unlikely this country will have a MH breakthrough and suddenly we have less patients. In fact, I anticipate depression/anxiety/etc to continue rise, especially as stigma continues to go down and more people seek treatment.

Where I work, im the only doctor for the most part, and theres 4 midlevels. Frequently I have people who refuse to see the NPs and I work in a underserved setting so yea, imagine how that would be in a commercial clinic.

Unless America suddenly becomes a utopia where everyone gets along, I think well be alright.

 

[Merovinge]

Unless America suddenly becomes a utopia where everyone gets along, I think well be alright.

Very hard to imagine our two party system X very high wealth inequality X ongoing perfection of propaganda/disinformation X global warming is going to lead to a reduction in mental health concerns at any point in the foreseeable future.

The likelihood of demand going down in psychiatry is much lower than most fields (e.g. rad onc).

 

[comp1]

You're good. Demand is so high. Salaries have not gone down (ever). If you are truly paranoid, the cash practices will always be there, but seriously, you have such bigger concerns as a MS1!! Worry about patient access to care if you need something to focus on.

 

[liquidshadow22]

You are wrong to be worried. I have answered many of these similar threads, but don't be influenced by chicken little. NPs and PA's intrusions into our field is a symptom of our lack of ability to provide for the need. It is supply and demand and we are rare and well paid. A lot of Mid levels do or jobs poorly, and GPs do most of our work very poorly. We do add value that isn't replaced by mid levels and if you don't see that, you probably don't belong in psychiatry or you are poorly trained. There are poorly trained psychiatrists out in the practicing world, but hopefully they see their limits and so should all of us. I have not been impressed with the judgement of unsupervised NPs. I have also been aware of some NPs that are better than some psychiatrists. It depends on who is teaching/supervising the mid-levels.

It's great that psychiatrists see the value in their training. However I don't think many uneducated patients/ insurance companies /large hospital employers/ lawmakers necessarily do.

 

[deleted1100659]

It's great that psychiatrists see the value in their training. However I don't think many uneducated patients/ insurance companies /large hospital employers/ lawmakers necessarily do.

this isnt specific to psych though, this applies to all medicine. We can still insist upon our value unless we all start agreeing to take a huge paycut

 

[liquidshadow22]

this isnt specific to psych though, this applies to all medicine. We can still insist upon our value unless we all start agreeing to take a huge paycut

It's not specific to psych but cognitive specialties are at highest risk for being commoditized. Plenty of NPs will be managing psych meds without losing their license and hospital systems will make plenty of money, in fact 85% insurance reimbursement of a psychiatrist or 100% if under supervision, while being paid less than a psychiatrist by perhaps an average of 40 to 50%. There is a reason why newly minted ER doctors can't find jobs anymore. Obviously there is a ton of demand for mental health services but it's naive to think it won't have any impact on job pay or availability in the future for a cognitive discipline like psych.

No NP is going to walk into an OR and be privileged to perform a craniotomy. Too much risk for a hospital system.

 

[deleted1100659]

It's not specific to psych but cognitive specialties are at highest risk for being commoditized. Plenty of NPs will be managing psych meds without losing their license and hospital systems will make plenty of money, in fact 85% insurance reimbursement of a psychiatrist or 100% if under supervision, while being paid less than a psychiatrist by perhaps an average of 40 to 50%. There is a reason why newly minted ER doctors can't find jobs anymore. Obviously there is a ton of demand for mental health services but it's naive to think it won't have any impact on job pay or availability in the future for a cognitive discipline like psych.

No NP is going to walk into an OR and be privileged to perform a craniotomy. Too much risk for a hospital system.

know how many midlevels are confident/excel at managing complex psych patients?

very, very few

 

[PikminOC]

We have a unique and powerful differentiating factor which is 4 years of residency. Those 4 years challenge us to formulate/conceptualize/diagnose our patients and then be able to justify those conceptualizations to hopefully thoughtful and experienced supervisors. That process refines our ability to clarify the root issues, whether diagnostic/phenomenological or psychological/dynamic, which is the bedrock beneath our treatment plans.

This unique differentiator is almost impossible for the average NP or PA to attain. They fill a void doing a hopefully better job than GP's in absorbing the huge demand for mental health services but they are not a replacement for us.

An analogous gap in the rest of the medical world is neurology. The neurological exam is king and being able to do a truly high quality, focused, effective, repeatable, accurate neuro exam takes years of training.

Patients don't care. They just want to know who is in their insurance to fill their Adderall and benzo.

 

[PikminOC]

You are wrong to be worried. I have answered many of these similar threads, but don't be influenced by chicken little. NPs and PA's intrusions into our field is a symptom of our lack of ability to provide for the need. It is supply and demand and we are rare and well paid. A lot of Mid levels do or jobs poorly, and GPs do most of our work very poorly. We do add value that isn't replaced by mid levels and if you don't see that, you probably don't belong in psychiatry or you are poorly trained. There are poorly trained psychiatrists out in the practicing world, but hopefully they see their limits and so should all of us. I have not been impressed with the judgement of unsupervised NPs. I have also been aware of some NPs that are better than some psychiatrists. It depends on who is teaching/supervising the mid-levels.

Doesn't matter if you aren't impressed with midlevels. Patients don't care.

 

[PikminOC]

You're good. Demand is so high. Salaries have not gone down (ever). If you are truly paranoid, the cash practices will always be there, but seriously, you have such bigger concerns as a MS1!! Worry about patient access to care if you need something to focus on.

He's right to worry. The infiltration will be much worse in 8 years.

 

[PikminOC]

You are wrong to be worried. I have answered many of these similar threads, but don't be influenced by chicken little. NPs and PA's intrusions into our field is a symptom of our lack of ability to provide for the need. It is supply and demand and we are rare and well paid. A lot of Mid levels do or jobs poorly, and GPs do most of our work very poorly. We do add value that isn't replaced by mid levels and if you don't see that, you probably don't belong in psychiatry or you are poorly trained. There are poorly trained psychiatrists out in the practicing world, but hopefully they see their limits and so should all of us. I have not been impressed with the judgement of unsupervised NPs. I have also been aware of some NPs that are better than some psychiatrists. It depends on who is teaching/supervising the mid-levels.

Who is supervising the midlevels? There are physicians who say they are supervising, which means nothing from 60 miles away multiple midlevels. And they don't even have to be psychiatrists who are supervising. The doctor is only there to absorb the lawsuit.

 

[PikminOC]

Very hard to imagine our two party system X very high wealth inequality X ongoing perfection of propaganda/disinformation X global warming is going to lead to a reduction in mental health concerns at any point in the foreseeable future.

The likelihood of demand going down in psychiatry is much lower than most fields (e.g. rad onc).

Demand will go up but so will the number of midlevels

 

[PikminOC]

know how many midlevels are confident/excel at managing complex psych patients?

very, very few

They are confident at it. Doesnt mean they manage them well. And I don't want all complex patients

 

[heartsink]

know how many midlevels are confident/excel at managing complex psych patients?

very, very few

If you don't know a problem is complex, its easy to feel confident in solving it.

 

[Old&InTheWay]

Patients don't care. They just want to know who is in their insurance to fill their Adderall and benzo.

I'll be more than happy if all these patients end up going to see NPs. I'll keep seeing the patients who are interested in getting better. Also happy to go into PP if it gets bad enough.

 

[FlowRate]

Patients don't care. They just want to know who is in their insurance to fill their Adderall and benzo.

Those patients won't be long in my panel so they have no effect on my current or future practice. I'd actually be relieved if committed med seekers skipped me entirely. There are all sorts of markets you can target. You can be a doormat drug dealer. You can be a scammy pseudo-science snake-oil salesman. Those are easy niches for midlevels to compete. Or you can provide excellent clinical care. There are plenty of patients who value and care about quality.

 

[deleted1100659]

Those patients won't be long in my panel so they have no effect on my current or future practice. I'd actually be relieved if committed med seekers skipped me entirely. There are all sorts of markets you can target. You can be a doormat drug dealer. You can be a scammy pseudo-science snake-oil salesman. Those are easy niches for midlevels to compete. Or you can provide excellent clinical care. There are plenty of patients who value and care about quality.

100%. Ive had to tell the staff here that just because a patient endorses a sx, doesnt mean they need a med for it. "What if they don't come back?". Well then they don't come back and now theres a spot for a patient who wants help rather than just as many sedating medications as possible..

 

[deleted456421]

I completely understand that people have been predicting doom and gloom for medicine for years, which seems akin to Chicken Little yelling at the sky since many of us are doing better than we would have years ago. However, I've witnessed psychiatrists replaced with NPs at various inpatient and outpatient positions. In fact, I quit moonlighting at a certain location solely because the institution went from 100% psychiatrists to 50/50 MD/NP. I literally had a pharmacist begging me to de-prescribe a patient managed negligently by their NPs.

I switched jobs in the same geographic area and guess what? One of these NPs from my inpatient moonlighting job, whom I knew was a terrible NP, transitioned to an outpatient gig and the medical director was happy with her documentation. Evidently documentation is as important as good psychiatric management, despite their abhorrent prescribing practices.

Anyone here who misunderstands the threat of mid-levels is incredibly naïve. Just look at pathology (taken over by private interests) and emergency medicine (overrun by the same types now encroaching on psychiatry). We're headed down the same trajectory since our specialty is often considered less than specialties such as surgery.

 

[bltzybltz]

I completely understand that people have been predicting doom and gloom for medicine for years, which seems akin to Chicken Little yelling at the sky since many of us are doing better than we would have years ago. However, I've witnessed psychiatrists replaced with NPs at various inpatient and outpatient positions. In fact, I quit moonlighting at a certain location solely because the institution went from 100% psychiatrists to 50/50 MD/NP. I literally had a pharmacist begging me to de-prescribe a patient managed negligently by their NPs.

I switched jobs in the same geographic area and guess what? One of these NPs from my inpatient moonlighting job, whom I knew was a terrible NP, transitioned to an outpatient gig and the medical director was happy with her documentation. Evidently documentation is as important as good psychiatric management, despite their abhorrent prescribing practices.

Anyone here who misunderstands the threat of mid-levels is incredibly naïve. Just look at pathology (taken over by private interests) and emergency medicine (overrun by the same types now encroaching on psychiatry). We're headed down the same trajectory since our specialty is often considered less than specialties such as surgery.

 

[hebel]

Hi all! MS1 wondering what your takes are on the future of psychiatry. To be honest, it seems like by the time I graduate and complete residency, most staff-type positions (hospital inpatient, clinics, prisons) are going to be staffed by several NPs rather than a psychiatrist. Based on my readings, it seems like the future of psychiatry is private practice, which is cool but I'm not necessarily very entrepreneurial.

Am I wrong to be worried? Are these jobs likely to be available in 7-10 years down the road? Would you recommend against going into psychiatry if I'm worried about finding a job in a typical populated metro area in 7-10 years?

May you don't realize it, but you've actually partly described why psychiatry is a good "cognitive" specialty choice.

Any specialty that requires an employer is at risk of many kinds of future threats. Psychiatry's current relative ease of doing private practice is a big advantage to it's future.

Yes, you might be safer doing surgery, but I wouldn't go down such a miserable career path just to avoid NP encroachment.

 

[PikminOC]

It's great that psychiatrists see the value in their training. However I don't think many uneducated patients/ insurance companies /large hospital employers/ lawmakers necessarily do.

Hospitals like midlevels as they cost three times less than a physician

 

[bltzybltz]

Can US psychiatrists at least practice in Canada if the situation is dire? I see that there are only 5,000 NPs in Canada vs 500,000 in the US. Is it a tough process to migrate north?

 

[WisNeuro]

Can US psychiatrists at least practice in Canada if the situation is dire? I see that there are only 5,000 NPs in Canada vs 500,000 in the US. Is it a tough process to migrate north?

We looked into it. Without a spouse who has citizenship, it can be a difficult process. However, it's easier for doctoral level healthcare providers, easier still if it's a position of shortage as you can more easily secure longer-term employment, which helps with the process. My psychologist credentials transfer as the APA/CPA have reciprocity, and my physician spouse looked into her end and felt like the process would not be overly onerous, but I don't know the specifics. We're keeping the option open in case of collapse of democracy And, we have a lot of Canadian friends, so that helps.

 

[MacDonaldTriad]

I completely understand that people have been predicting doom and gloom for medicine for years, which seems akin to Chicken Little yelling at the sky since many of us are doing better than we would have years ago. However, I've witnessed psychiatrists replaced with NPs at various inpatient and outpatient positions. In fact, I quit moonlighting at a certain location solely because the institution went from 100% psychiatrists to 50/50 MD/NP. I literally had a pharmacist begging me to de-prescribe a patient managed negligently by their NPs.

I switched jobs in the same geographic area and guess what? One of these NPs from my inpatient moonlighting job, whom I knew was a terrible NP, transitioned to an outpatient gig and the medical director was happy with her documentation. Evidently documentation is as important as good psychiatric management, despite their abhorrent prescribing practices.

Anyone here who misunderstands the threat of mid-levels is incredibly naïve. Just look at pathology (taken over by private interests) and emergency medicine (overrun by the same types now encroaching on psychiatry). We're headed down the same trajectory since our specialty is often considered less than specialties such as surgery.

I think the point that NPs really are dangerous and poorly monitored but so are our primary care brothermen. They don't do our job any better and do most of it. I'm not sure why we should go ballistic about NPs when GPs are doing the work equally badly and have been doing so for a very long time.

 

[liquidshadow22]

I think the point that NPs really are dangerous and poorly monitored but so are our primary care brothermen. They don't do our job any better and do most of it. I'm not sure why we should go ballistic about NPs when GPs are doing the work equally badly and have been doing so for a very long time.

No one is credentialing PCPs for insurance to see mental health patients. Psych departments/hospitals are not hiring PCPs to replace psychiatrists. PCPs are not opening up cash practices to act as psychiatrists. Psychiatric Mental Health NPs are doing all of the above.

 

[Orgone]

We looked into it. Without a spouse who has citizenship, it can be a difficult process. However, it's easier for doctoral level healthcare providers, easier still if it's a position of shortage as you can more easily secure longer-term employment, which helps with the process. My psychologist credentials transfer as the APA/CPA have reciprocity, and my physician spouse looked into her end and felt like the process would not be overly onerous, but I don't know the specifics. We're keeping the option open in case of collapse of democracy And, we have a lot of Canadian friends, so that helps.

Many Americans imagine it's much easier to get into Canada than it really is.

Relevant to this board, in Canada psychiatry residency is 5 years long. And their rules apparently are that to work independently you have to have done the same number of years, so anyone from the US who didn't do a fellowship has another serious hurdle. I've "heard" 2nd hand that there might be some work arounds involving getting supervision and/or somehow working/billing as family medicine (?), which is only 2 years residency in Canada.

 

[randomdoc1]

As someone out in private practice, I'm really not worried about it. The demand is high. But also, more and more patients are realizing the difference between provider levels and naturally, people tend to want to have a provider with more rigorous training. I also like to make lemonade out of lemons. NP practices make great referral places for patients who we do not work well with. Win win.

 

[comp1]

If you're worried enough about NPs to consider emigration to a country with lower reimbursement and higher taxes...I'm not sure there's anything anyone can say to reassure you.

 

[Styrene]

Hi all! MS1 wondering what your takes are on the future of psychiatry. To be honest, it seems like by the time I graduate and complete residency, most staff-type positions (hospital inpatient, clinics, prisons) are going to be staffed by several NPs rather than a psychiatrist. Based on my readings, it seems like the future of psychiatry is private practice, which is cool but I'm not necessarily very entrepreneurial.

Am I wrong to be worried? Are these jobs likely to be available in 7-10 years down the road? Would you recommend against going into psychiatry if I'm worried about finding a job in a typical populated metro area in 7-10 years?

Most psychiatrists are in private practice already. And in the busy suburban area where I am, it is still very difficult to find quality psychiatrists for open hospital faculty positions. The reason NPs are in the jobs you mentioned is because there are no psychiatrists to fill them.

 

[bltzybltz]

Most psychiatrists are in private practice already. And in the busy suburban area where I am, it is still very difficult to find quality psychiatrists for open hospital faculty positions. The reason NPs are in the jobs you mentioned is because there are no psychiatrists to fill them.

I just want to pay off my loans quickly and help people in a job that isn't a ****hole bcuz admin/oversaturation. Pray for me in 10 years.

 

[nowaysanjose]

I think the point that NPs really are dangerous and poorly monitored but so are our primary care brothermen. They don't do our job any better and do most of it. I'm not sure why we should go ballistic about NPs when GPs are doing the work equally badly and have been doing so for a very long time.

Let’s not compare the training of a physician to a midlevel. There are literally psych NPs out there who have started NP school completely online without any prior nursing experience, and the first time they even heard of many of the medicines we prescribe was when they got the job. A physician will always know their limits. I don’t see GPs starting the kind of obscene cocktails that NPs are. In fact, most will refer before even titrating meds to full effect. An NP will do the same but also add on an antipsychotic, mood stabilizer, benzo, stimulant, all at subtherapeutic doses until the pt zombies out or goes somewhere else.

 

[MacDonaldTriad]

You make a good point, but when you see the actual scripts being written, I'm not sure that a blinded reviewer could determine who was doing the writing. They are both clearly bad. One may be worse than the other, but they are both a big problem.

 

[comp1]

You make a good point, but when you see the actual scripts being written, I'm not sure that a blinded reviewer could determine who was doing the writing. They are both clearly bad. One may be worse than the other, but they are both a big problem.

That is what the vast majority of the literature says.

 

[hallowmann]

Let’s not compare the training of a physician to a midlevel. There are literally psych NPs out there who have started NP school completely online without any prior nursing experience, and the first time they even heard of many of the medicines we prescribe was when they got the job. A physician will always know their limits. I don’t see GPs starting the kind of obscene cocktails that NPs are. In fact, most will refer before even titrating meds to full effect. An NP will do the same but also add on an antipsychotic, mood stabilizer, benzo, stimulant, all at subtherapeutic doses until the pt zombies out or goes somewhere else.

Exactly this. Short of 60+ yo PCPs that prescribe benzos to everyone much like some of the 60+ yo private practice psychiatrists I see, PCPs will often just start low doses of meds and then refer.

They are often worried about serotonin syndrome whenever they consider another psychotropic, in most cases unnecessarily, not titrating SSRIs and SNRIs simultaneously because they're "different classes". They don't usually start someone on 2-3 antipsychotics because of "hallucinations" like hearing yourself self say that you're a failure. They may diagnose someone erroneously with bipolar disorder, but they're usually not doing that and then starting lithium without checking kidney functioning. They're usually not prescribing someone with OSA stimulants and benzos to manage the OSA sequelae. I've seen all of the above from NPs and not PCPs.

 

[WisNeuro]

Exactly this. Short of 60+ yo PCPs that prescribe benzos to everyone much like some of the 60+ yo private practice psychiatrists I see, PCPs will often just start low doses of meds and then refer.

They are often worried about serotonin syndrome whenever they consider another psychotropic, in most cases unnecessarily, not titrating SSRIs and SNRIs simultaneously because they're "different classes". They don't usually start someone on 2-3 antipsychotics because of "hallucinations" like hearing yourself self say that you're a failure. They may diagnose someone erroneously with bipolar disorder, but they're usually not doing that and then starting lithium without checking kidney functioning. They're usually not prescribing someone with OSA stimulants and benzos to manage the OSA sequelae. I've seen all of the above from NPs and not PCPs.

I wouldn't assume it's just the old practitioners. There are 3 candymen who go nuts with benzos here, 2 psych, 1 PCP, and they are all <50.

 

[dl2dp2]

I'm always a contrarian and based on my in-the-field experience I think the NP craze is peaking in this field. It's very interesting.

NP salary is stable/dropping. MD salary continues to rise. Something weird is happening in the real world. I'm not sure what exactly this is about. I'm talking about staff salary, not PP, which obviously continues to thrive.

I think one factor here is PMDs are starting to realize that MH is a niche PMD field they can move into quickly, and they are displacing NPs in typical NP jobs (low acuity outpatient insurance-driven practice).

Very interesting phenomenon if you think about it. If you are using insurance and have a low acuity MH issue, who would rather see? An MH NP of variable quality or your primary care MD who "specializes in MH"?

Nobody except psych actually want to deal with "real psych patients" with a 5-foot pole. These people don't stick in NP/PMD practices. I think psychiatry is just not nearly as scalable as anesthesia, urgent care, etc. For example, NPs are actually very bad fit for state hospital/inpatient jobs, so it's not that easy to just say let's hire 3 NPs to deal with a ward of SMIs or a full clinic of typical outpatients and replace the MD attending. They don't have the skills and appropriate training and actually cause more problems without proper supervision. And we are not even talking about malpractice problems, more like problems in revenue capture, retention, efficiency, regulatory, etc. Facilities are starting to realize this and the market is adjusting to this reality.

 

[psyspy]

Med student here. If NPs really do gobble up some of the bread/butter cases I guess that wouldn’t be the end of the world? We generally don’t necessarily need fellowships to exclusively build our practice around more complex cases, or will we ultimately need one?

And what is considered simple vs complex in psych?

 

[PsyDr]

At the height of the pandemic, the value of the MSN/NP license was dwarfed by the value of the RN license due to JCAHO, CMS, and state regulations. That process demonstrated the resiliency, and pervasiveness in regulation of the physician license. If I were a concerned physician, I would hire midlevels as a force-multiplier for income. Or use NP prices as a base negotiation point for insurances.

 

[calvnandhobbs68]

At the height of the pandemic, the value of the MSN/NP license was dwarfed by the value of the RN license due to JCAHO, CMS, and state regulations. That process demonstrated the resiliency, and pervasiveness in regulation of the physician license. If I were a concerned physician, I would hire midlevels as a force-multiplier for income. Or use NP prices as a base negotiation point for insurances.

Yeah just from random stuff I've seen and heard, there are quite a few NPs who just decided to go back and do RN work because the hourly rate was at least comparable and they could just "leave work at work". There was also this sense of an NP glut even before COVID...lots of subjective stories of NPs staying as an RN for a year or two while they were looking for a job or some job markets being so tight it was tough to even get a starting job.

I'll just put this out there but I also think there's this growing realization that the actual mentality around work is just inherently different between NPs in general and physicians. NPs tend to have a very RN approach to work...clock in, clock out, work should be over after I clock out. I'm here from 7-3 and you can't find me after 3. No i'm not going to talk to a therapist outside of work hours. No I'm not going to get curbsided by one of the IM docs as a courtesy with a patient question. No i'm not going to go read up on journal articles when I get home. Of course there's exceptions but the training structure is just incredibly different between RN training and physician training. Which is also a reason why employers are also finding that NPs don't tend to achieve the same productivity as physicians, even when you have them scheduled for the same amount of hours. So i think NPs salaries are going to end up finding a ceiling because at some point you actually aren't saving any money anymore.

 

[PsyDr]

Yeah just from random stuff I've seen and heard, there are quite a few NPs who just decided to go back and do RN work because the hourly rate was at least comparable and they could just "leave work at work". There was also this sense of an NP glut even before COVID...lots of subjective stories of NPs staying as an RN for a year or two while they were looking for a job or some job markets being so tight it was tough to even get a starting job.

I'll just put this out there but I also think there's this growing realization that the actual mentality around work is just inherently different between NPs in general and physicians. NPs tend to have a very RN approach to work...clock in, clock out, work should be over after I clock out. I'm here from 7-3 and you can't find me after 3. No i'm not going to talk to a therapist outside of work hours. No I'm not going to get curbsided by one of the IM docs as a courtesy with a patient question. No i'm not going to go read up on journal articles when I get home. Of course there's exceptions but the training structure is just incredibly different between RN training and physician training. Which is also a reason why employers are also finding that NPs don't tend to achieve the same productivity as physicians, even when you have them scheduled for the same amount of hours. So i think NPs salaries are going to end up finding a ceiling because at some point you actually aren't saving any money anymore.

Eh. To my untrained eye, it doesn't matter who is better. The regulatory environment extends far past simple licensing laws, and the RN is becoming more valuable than the NP.

 

[mistafab]

I can sit back and use my crystal ball as well as anyone.

I feel like the 2 tiered system we have in place will get more entrenched. People with bad insurance or gov insurance will get worse and worse care, get longer and longer waits. The race to the bottom as a provider here will push midlevels and primary care docs as the face of mental health practice, with psychiatrists acting as consultants on basic care, and primary providers for advanced mental health problems. I don't think we need to race to the bottom and try to push out the midlevels here as it is natural that the government will want cheap, unskilled labor to take on the majority of the burden -- that will keep psychiatrists available for the tougher cases, or working in more advanced hospital centers.

There is no reason for us to get involved with care that is delivered at the bottom of our license. Even in the uninsured/underinsured psychiatrists can already work at the top of their license by being employed in academic settings or tertiary care centers who help out the sickest patients. I don't think harvard is going to replace all doctors with nurses (bad example but go with it), as it would cheapen the reputation and would be unlikely to handle the cases that get referred there.

As for the 2nd tier (well-insured or cash pay), Psychiatrists have an edge in that we don't need to work with an employer. In the era of social media and mass marketing, psychiatrists have a definite edge in marketing and working for themselves, selecting who they want on their panel, and charging what they want. You don't have to be an entrepreneur to have a website that markets your skills for you. You take an elective in TMS or treatment resistant depression during residency, call yourself a "TMS expert" or "depression expert" on your website, and can see all the TMS/TRD cases you want. You can help people with the specific problem you want to see, and they'll come from far and wide to see you. You're the expert... right? They will get better and boom - now you feel good. Yay, mission accomplished. No NP can do that.

My question is, why is it a bad thing? Most hospitals are admitting anyone who says SI, putting them on a med to make them "better" and delivering this inferior care with an NP. Why do I care? That is not care I want to be delivering. It's akin to everyone calling themselves a "handyman" these days saying they can do carpentry. No they can't. Anyone who wants to have a custom set of wooden stairs made is going to hire an expert craftsman, an actual carpenter. Why would a carpenter want to come over and fix a broken toilet rim? Why as a psychiatrist do I want to see someone who feels "depressed" with "anxiety." You ask them all the questions and they are all essentially asymptomatic. Leave that to the NP who can prescribe xanax and adderall since they "can't focus" - what do I care? The actual sick people need my help, and their numbers are growing exponentially.

As more and more NP's attain full enlightenment (aka fully independent without supervision), they will get their assess sued for their terrible care. Plus, then I won't get forced to supervise them in my job when I graduate, and the company/hospital can't pretend it is needed for the NPs to practice. Let them deal with their own liability. I'd rather train doctors at becoming better doctors than train a supervised NP at becoming an inferior simulacrum of medicine.

 

[nowaysanjose]

I can sit back and use my crystal ball as well as anyone.

I feel like the 2 tiered system we have in place will get more entrenched. People with bad insurance or gov insurance will get worse and worse care, get longer and longer waits. The race to the bottom as a provider here will push midlevels and primary care docs as the face of mental health practice, with psychiatrists acting as consultants on basic care, and primary providers for advanced mental health problems. I don't think we need to race to the bottom and try to push out the midlevels here as it is natural that the government will want cheap, unskilled labor to take on the majority of the burden -- that will keep psychiatrists available for the tougher cases, or working in more advanced hospital centers.

There is no reason for us to get involved with care that is delivered at the bottom of our license. Even in the uninsured/underinsured psychiatrists can already work at the top of their license by being employed in academic settings or tertiary care centers who help out the sickest patients. I don't think harvard is going to replace all doctors with nurses (bad example but go with it), as it would cheapen the reputation and would be unlikely to handle the cases that get referred there.

As for the 2nd tier (well-insured or cash pay), Psychiatrists have an edge in that we don't need to work with an employer. In the era of social media and mass marketing, psychiatrists have a definite edge in marketing and working for themselves, selecting who they want on their panel, and charging what they want. You don't have to be an entrepreneur to have a website that markets your skills for you. You take an elective in TMS or treatment resistant depression during residency, call yourself a "TMS expert" or "depression expert" on your website, and can see all the TMS/TRD cases you want. You can help people with the specific problem you want to see, and they'll come from far and wide to see you. You're the expert... right? They will get better and boom - now you feel good. Yay, mission accomplished. No NP can do that.

My question is, why is it a bad thing? Most hospitals are admitting anyone who says SI, putting them on a med to make them "better" and delivering this inferior care with an NP. Why do I care? That is not care I want to be delivering. It's akin to everyone calling themselves a "handyman" these days saying they can do carpentry. No they can't. Anyone who wants to have a custom set of wooden stairs made is going to hire an expert craftsman, an actual carpenter. Why would a carpenter want to come over and fix a broken toilet rim? Why as a psychiatrist do I want to see someone who feels "depressed" with "anxiety." You ask them all the questions and they are all essentially asymptomatic. Leave that to the NP who can prescribe xanax and adderall since they "can't focus" - what do I care? The actual sick people need my help, and their numbers are growing exponentially.

As more and more NP's attain full enlightenment (aka fully independent without supervision), they will get their assess sued for their terrible care. Plus, then I won't get forced to supervise them in my job when I graduate, and the company/hospital can't pretend it is needed for the NPs to practice. Let them deal with their own liability. I'd rather train doctors at becoming better doctors than train a supervised NP at becoming an inferior simulacrum of medicine.

It seems like the ivory tower places are just as likely (maybe moreso) to push midlevels than anyone else.

There’s now a bill in Virginia (sponsored by a DNP who happens to go by “doctor”) proposing that NPs can practice independently after 2 years of being supervised by another NP, and another provision removes any requirement for them to carry malpractice insurance.

 

[dl2dp2]

It seems like the ivory tower places are just as likely (maybe moreso) to push midlevels than anyone else.

There’s now a bill in Virginia (sponsored by a DNP who happens to go by “doctor”) proposing that NPs can practice independently after 2 years of being supervised by another NP, and another provision removes any requirement for them to carry malpractice insurance.

I think you have to be hyper-realistic about the world. The reality is that malpractice is not sufficiently hard a hammer to be rid of NPs. They only make NPs less winning to be treating sicker patients and prescribing meds with side effects.

Another reality is that SOME psychiatrists WILL bear the brunt of this dynamic. Everyone knows who they are. I spelled that out explicitly once and got into dodo on this forum so I’m not gonna say that outloud that now. If you think you belong to that category you need to be careful and think about things like fellowship, job experience, etc. and make a conscious effort building your resume. If you are a middling med student you should be concerned and aim to match as well as you can. If you want to do PP the market is quite ruthless and not everyone can make it work as a business owner.

Psychiatry is already in the top 10 most competitive specialties at this point, and I’d say the top 50 programs in psych now are on par with or perhaps more competitive than the average ROAD programs. The secret is kind of out at this point. Yes if you do things right this can be one of the sweetest gigs in medicine, but if you don’t, you may very well end up on the chopping block as NP fodder. Live and learn and don’t stop seeking excellence. You are not wrong to be “worried”, but aim to translate that worry into action to do as well as you can.

If your question is whether you should rethink lower tier residency vs some other specialty, I think it’s a very individualized answer. As of right now psych is probably one of the best gigs for candidates who are a match for that kind of program vis-a-vis for a program in a different specialty. Ie you ain’t matching in derm if you are looking at a lower tier psych program as an alternative. Out of the other alternatives are mainly lower tier cognitive specialties. I actually personally don’t think these are categorically better choices w r t long term NP encroachment as an issue. These are all very different pathways so it’s very hard to generalize. More technical pathways WILL have less encroachment—if you match into a lower tier IM program and then do really well and match into a lower tier heme onc fellowship, etc. that sort of pathway is clearly less susceptible to these issues. But there are OTHER issues. Is the heme onc job market for such a candidate necessarily better than a lower tier psych grad in a metro in 10 years? It’s REALLY unclear, but it has nothing to do with NP encroachment of the former.

 

[mistafab]

It seems like the ivory tower places are just as likely (maybe moreso) to push midlevels than anyone else.

There’s now a bill in Virginia (sponsored by a DNP who happens to go by “doctor”) proposing that NPs can practice independently after 2 years of being supervised by another NP, and another provision removes any requirement for them to carry malpractice insurance.

I feel like this is just not true at all. DNPs are not that bright and have zero potential for research and grants. Ivory towers are not going to use NPs when they want to be pumping in grant funds and recruiting talented physicians. There is nothing to gain for using NPs there when they are recruiting residents and getting medicare to pay for it. They have alll these FTEs to fill and many young attendings wanting protected research time but dont have the grants yet to be full 1fte researchers. Even the top physicians are doing .5-.8 fte in research, with some admin and a half day of clinic here or there thrown in. The clinical work is not where the department is making money anyway.

 

[bGMx]

I think you have to be hyper-realistic about the world. The reality is that malpractice is not sufficiently hard a hammer to be rid of NPs. They only make NPs less winning to be treating sicker patients and prescribing meds with side effects.

Another reality is that SOME psychiatrists WILL bear the brunt of this dynamic. Everyone knows who they are. I spelled that out explicitly once and got into dodo on this forum so I’m not gonna say that outloud that now. If you think you belong to that category you need to be careful and think about things like fellowship, job experience, etc. and make a conscious effort building your resume. If you are a middling med student you should be concerned and aim to match as well as you can. If you want to do PP the market is quite ruthless and not everyone can make it work as a business owner.

Psychiatry is already in the top 10 most competitive specialties at this point, and I’d say the top 50 programs in psych now are on par with or perhaps more competitive than the average ROAD programs. The secret is kind of out at this point. Yes if you do things right this can be one of the sweetest gigs in medicine, but if you don’t, you may very well end up on the chopping block as NP fodder. Live and learn and don’t stop seeking excellence. You are not wrong to be “worried”, but aim to translate that worry into action to do as well as you can.

If your question is whether you should rethink lower tier residency vs some other specialty, I think it’s a very individualized answer. As of right now psych is probably one of the best gigs for candidates who are a match for that kind of program vis-a-vis for a program in a different specialty. Ie you ain’t matching in derm if you are looking at a lower tier psych program as an alternative. Out of the other alternatives are mainly lower tier cognitive specialties. I actually personally don’t think these are categorically better choices w r t long term NP encroachment as an issue. These are all very different pathways so it’s very hard to generalize. More technical pathways WILL have less encroachment—if you match into a lower tier IM program and then do really well and match into a lower tier heme onc fellowship, etc. that sort of pathway is clearly less susceptible to these issues. But there are OTHER issues. Is the heme onc job market for such a candidate necessarily better than a lower tier psych grad in a metro in 10 years? It’s REALLY unclear, but it has nothing to do with NP encroachment of the former.

Hi, can I PM you? I'm not able to start a conversation due to settings on your account, I believe.