Future of Psychiatry With NPs Practicing Independently

[dl2dp2]

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

I had bad experiences with PM here so if you have a question just ask here.

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[bGMx]

I had a couple identifying questions I'd like to ask you, but aside, what kind of things should an M2 soon to be M3 from top 30-40 medical school do that is actionable right now? I think I have my research bases covered, as well as prior working experience and leadership qualifications through restarting the school's psychiatry student interest group. My goal is to be the best psychiatrist I can possibly be with long term goal in addiction or forensic psychiatry (w/ fellowship?) and desire at the moment to run an effective and marketable PP.

 

[nowaysanjose]

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.

Both Harvard and Yale offer NP/PA “fellowships” fwiw

 

[romanticscience]

I had a couple identifying questions I'd like to ask you, but aside, what kind of things should an M2 soon to be M3 from top 30-40 medical school do that is actionable right now? I think I have my research bases covered, as well as prior working experience and leadership qualifications through restarting the school's psychiatry student interest group. My goal is to be the best psychiatrist I can possibly be with long term goal in addiction or forensic psychiatry (w/ fellowship?) and desire at the moment to run an effective and marketable PP.

You may want to become politically involved through APA and its med student branch psychsign. Now, just “being a member” won’t help that much; however, making connections with people in quality programs will. Program directors love academic psychiatry. So, even with eyes on private practice, you can show interest in the ivory tower. It’s also good to seek out people at your med school who have affiliation with the name brand programs. It’s hard to differentiate yourself in med school outside of grades but these experiences now will put your name to a face come match time. Dig your well before you’re thirsty

Also, last idea. Consider doing audition rotations at programs where the PD will supervise you.

 

[hallowmann]

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.

This is not how it plays out in practice. Some of the most vulnerable in my community, especially those with SMI just get terrible care from non-physicians contracted by some huge telepsych company. There are also multiple Ivory tower settings training and hiring NPs to manage patients and give their attendings more time for research and administrative tasks. No one notices until they end up in the hospital and are then sent out to the same care environment. No one really advocates for them because they have poor supports to begin with.

If NPs only treated moderate unipolar depression and anxiety with monotherapy and referred out when things got complicated, I don't think anyone would have an issue with this. The issue is that there is no triage or sorting at this point. There is no working to the "top" of our license, because many of them are acting like their top and our top are the same. That's the issue.

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.

Yeah this post is very much not what I am seeing. Academic institutions are in the forefront of the push for heavy utilization of NPs in all departments. This started when they could no longer force residents to work 120 hr/wk with no didactics. It's only expanded from there. They saw it as the next cheap labor and have been expanding their scope since. There is also a significant incentive internally because most administrators have a nursing or NP background so they look out for their own, something I would argue physicians do a poor job at.

All of the APP "residencies" are in these academic institutions and even their training programs seem to take precedent over residents in some cases, because the hospital's goal is basically hiring them for "on the job" training at a lower price tag with the plan that they'll stay on, which many do because they are already comfortable with the system and get a pay raise.

 

[Merovinge]

There is also a significant incentive internally because most administrators have a nursing or NP background so they look out for their own, something I would argue physicians do a poor job at.

This trend really baffles me, I don't understand where the brother/sisterhood of medicine went? I always go out of my way to help any aspiring med student/resident and treat them like the future colleagues they are because this was the culture of my medical school (and it's the right thing to do). I routinely encounter a lack of collegiality between specialties in the attending world and I just do not understand it. Between administration, government, mid levels, patients, and the actual job of being a doctor there is so much going on, it really saddens me that we don't do a better job having each other's backs.

 

[nowaysanjose]

This trend really baffles me, I don't understand where the brother/sisterhood of medicine went? I always go out of my way to help any aspiring med student/resident and treat them like the future colleagues they are because this was the culture of my medical school (and it's the right thing to do). I routinely encounter a lack of collegiality between specialties in the attending world and I just do not understand it. Between administration, government, mid levels, patients, and the actual job of being a doctor there is so much going on, it really saddens me that we don't do a better job having each other's backs.

You see this a lot with surgeons and CRNAs. That entire movement could be stopped dead in its tracks right now if surgery just came out said, “you know what, this is really a pt safety issue, and we’re not gonna operate if anesthesiologists are not in here.” I’ve heard many anecdotal reports of horrible outcomes with CRNAs from surgeons, but at the same time they like having them because they will rarely push back on surgeon recs or cancel potentially unsafe cases. Surgery needs to stand up for Anesthesiology just like we need to stand for our primary care brethren.

 

[nexus73]

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.

what does go nuts with benzos mean specifically?

 

[WisNeuro]

what does go nuts with benzos mean specifically?

In my population (60+), maintenance xanax for mild to moderate anxiety, usually 1mg at a time. This is usually in addition to other CNS altering drugs and those with anticholinergic side effects. I know exactly who I'd go to in town if I wanted benzos and/or opiates pretty easily, and most of them are middle aged physicians. Also, all male for some reason. I don't personally know any candywomen in town.

 

[WisNeuro]

Tangentially related to this thread. NP cold-faxed my office a resume yesterday. Weird, also typo ridden.

 

[mistafab]

Tangentially related to this thread. NP cold-faxed my office a resume yesterday. Weird, also typo ridden.

Thats a power move

 

[nexus73]

Tangentially related to this thread. NP cold-faxed my office a resume yesterday. Weird, also typo ridden.

Helloe, fellow psyciatric provider.

 

[WisNeuro]

Helloe, fellow psyciatric provider.

Yeah, it was weird, verb tense changed a lot, sometimes within the same sentence. Also, places are hiring like crazy for psychiatrists and psych NPs, so it seems weird to just blanket resume random clinics.

 

[deleted941485]

Yeah, it was weird, verb tense changed a lot, sometimes within the same sentence. Also, places are hiring like crazy for psychiatrists and psych NPs, so it seems weird to just blanket resume random clinics.

Probably not from US and possibly a bad past

 

[WisNeuro]

Probably not from US and possibly a bad past

All US education, and a very generic first and last name. Maybe on the bad past part.

 

[Taddy Mason]

what does go nuts with benzos mean specifically?

I’d call this going nuts. Med regimen for a 60-some year-old we were consulted on the other day for AMS:
Xanax 1mg qid
Xanax ER 1mg bid
Ambien 10mg qhs
Soma 350mg tid
Lyrica 200mg tid
Trazodone 200mg qhs

All from the same 2-3 NPs.

 

[WisNeuro]

I’d call this nuts. Med regimen for a 60-some year-old we were consulted on the other day for AMS:
Xanax 1mg qid
Xanax ER 1mg bid
Ambien 10mg qhs
Soma 350mg tid
Lyrica 200mg tid
Trazodone 200mg qhs

All from the same 2-3 NPs.

No oxybutynin to round out the adverse med effects?

 

[Taddy Mason]

No oxybutynin to round out the adverse med effects?

Probably wouldn’t hurt to help with any incontinence with how sedated he is 24/7.

I’ll also add that he was pretty consistently taking close to double both the Xanax and Xanax ER, and often the Ambien as well. Soma and Lyrica were both being prescribed for anxiety…

 

[michaelrack]

This trend really baffles me, I don't understand where the brother/sisterhood of medicine went? I always go out of my way to help any aspiring med student/resident and treat them like the future colleagues they are because this was the culture of my medical school (and it's the right thing to do). I routinely encounter a lack of collegiality between specialties in the attending world and I just do not understand it. Between administration, government, mid levels, patients, and the actual job of being a doctor there is so much going on, it really saddens me that we don't do a better job having each other's backs.

The brotherhood went away with the rise of corporate medicine. There didn't use to be much of a sisterhood

 

[ObsequiousAplomb]

I’d call this going nuts. Med regimen for a 60-some year-old we were consulted on the other day for AMS:
Xanax 1mg qid
Xanax ER 1mg bid
Ambien 10mg qhs
Soma 350mg tid
Lyrica 200mg tid
Trazodone 200mg qhs

All from the same 2-3 NPs.

People still prescribe Soma? I guess I learn something new every day.

 

[WisNeuro]

Probably wouldn’t hurt to help with any incontinence with how sedated he is 24/7.

I’ll also add that he was pretty consistently taking close to double both the Xanax and Xanax ER, and often the Ambien as well. Soma and Lyrica were both being prescribed for anxiety…

Was this person able to actually have an intelligible conversation? Did they drive themselves to the appointment?

 

[Taddy Mason]

Was this person able to actually have an intelligible conversation? Did they drive themselves to the appointment?

We saw him inpatient after family took him to the ED for becoming progressively more altered over the past 2 weeks and were consulted because of his med regimen. Med and neuro work-up were pretty unremarkable. He was s/p phenobarb loading, definitely delirious, and unable to engage in meaningful conversation when we first saw him. Cleared quite a bit later in the afternoon and was able to give a history pretty consistent with what we found in the prescriber database, talking to family, and talking to some prescribers. MS has been fluctuating but trending in the right direction. Utox had bup which he adamantly denies taking so was sent for confirmatory testing.

 

[Mad Jack]

Will it be a problem? Yes. Will it be a problem that significantly impairs our careers over the next 15-20 years? Unlikely. There are legal and other factors at play that make psychiatrists necessary in many states, from medical direction to commitment procedures. Couple that with less ability and productivity in NPs versus physicians (typically their caseloads are about 50-60% of what a physician sees and they often refuse more difficult cases) and market forces that favor physicians (psychiatry is more customer-oriented than most fields, and when customers are choosing they tend to want the best) and I just don't see it being a major factor any time soon.

 

[Mad Jack]

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.

Where I was doing outpatient, typically our NPs would see 10-12 patients per day while physicians would see 18-20. This is before cancelations, of course, so those numbers would usually be closer to 8-9 and 14-15. Couple that with NPs being unwilling to see "complex" patients (basically anyone with even moderate risk or more than two or three meds) and their refusal to take call or do consults and physicians were just a better deal overall. Patient satisfaction also tended to be much higher with physicians, despite the significantly increased time with NPs.

 

[Mad Jack]

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.

Ironically most of the really successful PP psychiatrists I've worked with (7 figure plus guys) were from Caribbean or lower ranked schools that had built practices where they were essentially managers that only did about .5 FTE of clinical work for VIPs and everything else was done by NPs and physicians they hired. Making money in PP is more about business acumen than pedigree, though pedigree certainly helps.

 

[dl2dp2]

Ironically most of the really successful PP psychiatrists I've worked with (7 figure plus guys) were from Caribbean or lower ranked schools that had built practices where they were essentially managers that only did about .5 FTE of clinical work for VIPs and everything else was done by NPs and physicians they hired. Making money in PP is more about business acumen than pedigree, though pedigree certainly helps.

Sure. I don't disagree. However, I don't see any alternative here: don't study and don't match well. And then what exactly? What's the pathway? How do you "learn" to be a business owner? This track is even less defined. MOST of those types are not getting 7 figures plus.

Secondly, the straight cash practices that generate 7 figures plus are not a viable alternative for that group.

Once you are IN a good residency program, I agree that the emphasis changes somewhat: if you want to do well in PP, you should start learning about the system ASAP. Don't stress about clinical evaluations, that sort of thing. Spend more time understanding how you can actually make money in this business.

 

[Merovinge]

Sure. I don't disagree. However, I don't see any alternative here: don't study and don't match well. And then what exactly? What's the pathway? How do you "learn" to be a business owner? This track is even less defined. MOST of those types are not getting 7 figures plus.

Secondly, the straight cash practices that generate 7 figures plus are not a viable alternative for that group.

Once you are IN a good residency program, I agree that the emphasis changes somewhat: if you want to do well in PP, you should start learning about the system ASAP. Don't stress about clinical evaluations, that sort of thing. Spend more time understanding how you can actually make money in this business.

This really depends on what you are looking for. Clinical excellence gets you referrals from other professionals once you are a known entity in an area, even some patients will prefer someone who a strong working understanding of the latest literature and can explain things to them in a health-literacy appropriate manner (and let's be clear, in high end cash pay there's plenty that want to know the neurobiology). You still need to learn from people doing PP how to run a business, listen to whitecoatinvestor, etc, but I certainly wouldn't do so at the expense of clinical knowledge, it's incumbent upon you to do both.

At the end of the day, you did swear an oath to be a doctor, if it's just $$ you want, do non-clinical work with your degree. You can be like Dr. Phil and give up your clinical license if you want to sell out.

 

[Mad Jack]

Sure. I don't disagree. However, I don't see any alternative here: don't study and don't match well. And then what exactly? What's the pathway? How do you "learn" to be a business owner? This track is even less defined. MOST of those types are not getting 7 figures plus.

Secondly, the straight cash practices that generate 7 figures plus are not a viable alternative for that group.

Once you are IN a good residency program, I agree that the emphasis changes somewhat: if you want to do well in PP, you should start learning about the system ASAP. Don't stress about clinical evaluations, that sort of thing. Spend more time understanding how you can actually make money in this business.

Oh you should absolutely go to the best residency possible. But a good residency does little to prepare one for business, nor does a bad residency hinder it. Business skills are entirely separate from medical skills and not something residency builds, and I would argue more inherently tied to personality traits related to risk tolerance and personal drive than anything else. The sorts of personalities medicine selects for are those that are risk averse but highly motivated, so it seems likely to me that the reason people that make it to highly selective programs do well is more due to the degree of motivation that led to their achieving so highly overpowering their inherent risk aversion than it is to the residency they ended up attending.

The same correlation not equaling causation effect has been noted in studies of undergraduates that were accepted to highly selective institutions but chose to attend less selective ones. They ended up achieving similar outcomes to peers that went to the more selective institutions, despite lackluster pedigrees. I doubt medicine is such an unusual field that results would differ were such a study performed on residents.

 

[bGMx]

Once you are IN a good residency program, I agree that the emphasis changes somewhat: if you want to do well in PP, you should start learning about the system ASAP. Don't stress about clinical evaluations, that sort of thing. Spend more time understanding how you can actually make money in this business.

Any reads you suggest, be it blog or book?

 

[PikminOC]

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.

Hopkins has np doing Colonoscopies a long time ago.

 

[randomdoc1]

Any reads you suggest, be it blog or book?

Or you can do what I did and sort of blindly rent a small office space and roll with it lol! Learned through trial and error how to collect patient responsibility and get claims processed successfully through insurance. Doesn't take many denied claims/payments to figure it out lmao. My piece of advice, get a damn good EMR (do not think about the price, it will certainly pay for itself) with good integration with billing clearinghouses and patient payments so the accounting is clear as heck and you can easily pull up profit and loss reports by exporting the data. That has been a life saver.

 

[liquidshadow22]

Or you can do what I did and sort of blindly rent a small office space and roll with it lol! Learned through trial and error how to collect patient responsibility and get claims processed successfully through insurance. Doesn't take many denied claims/payments to figure it out lmao. My piece of advice, get a damn good EMR (do not think about the price, it will certainly pay for itself) with good integration with billing clearinghouses and patient payments so the accounting is clear as heck and you can easily pull up profit and loss reports by exporting the data. That has been a life saver.

Charm seems like a good bet for this? Or valent?

 

[KoolKeith]

Oh you should absolutely go to the best residency possible. But a good residency does little to prepare one for business, nor does a bad residency hinder it. Business skills are entirely separate from medical skills and not something residency builds, and I would argue more inherently tied to personality traits related to risk tolerance and personal drive than anything else. The sorts of personalities medicine selects for are those that are risk averse but highly motivated, so it seems likely to me that the reason people that make it to highly selective programs do well is more due to the degree of motivation that led to their achieving so highly overpowering their inherent risk aversion than it is to the residency they ended up attending.

The same correlation not equaling causation effect has been noted in studies of undergraduates that were accepted to highly selective institutions but chose to attend less selective ones. They ended up achieving similar outcomes to peers that went to the more selective institutions, despite lackluster pedigrees. I doubt medicine is such an unusual field that results would differ were such a study performed on residents.

I'd love to hear what you think makes a good residency. I have read on here many times that, like medical school, it doesn't matter where you go for residency unless you want to do academia. I have a hard time believing that, as in my experience, name matters quite a bit. I am currently trying to decide between ranking my decent, but unknown local program over several top programs that I would require me to move my family across the country. Any insight would be appreciated.

 

[dl2dp2]

I'd love to hear what you think makes a good residency. I have read on here many times that, like medical school, it doesn't matter where you go for residency unless you want to do academia. I have a hard time believing that, as in my experience, name matters quite a bit. I am currently trying to decide between ranking my decent, but unknown local program over several top programs that I would require me to move my family across the country. Any insight would be appreciated.

Everything matters. However, if you decide that you don't want to move, it probably will matter less. This is just common sense, right? Even if you decide that you want to move back to small-town USA, if you trained at Big Name U, people in town will still look at you differently. But is this effect strong enough to alter any "meaningful" outcome? Likely not.

 

[Mad Jack]

I'd love to hear what you think makes a good residency. I have read on here many times that, like medical school, it doesn't matter where you go for residency unless you want to do academia. I have a hard time believing that, as in my experience, name matters quite a bit. I am currently trying to decide between ranking my decent, but unknown local program over several top programs that I would require me to move my family across the country. Any insight would be appreciated.

A good residency is one that is both suited to your goals and that doesn't hand a reputation for malignancy or board failures. What that is will vary from person to person. There's wonderful places on paper out there that would have made me miserable, and more lackluster places where I would thrive. A lot of people put emphasis on name, but personally I'm one that emphasizes fit. I'm just some guy with an opinion though, there's no right way to think about this.

 

[romanticscience]

I'd love to hear what you think makes a good residency. I have read on here many times that, like medical school, it doesn't matter where you go for residency unless you want to do academia. I have a hard time believing that, as in my experience, name matters quite a bit. I am currently trying to decide between ranking my decent, but unknown local program over several top programs that I would require me to move my family across the country. Any insight would be appreciated.

Here's my opinion about "good." There is "good" from an experience standpoint; does the residency expose you to a wide breadth of patients from a pathological, severity/treatment setting, and across the lifespan. Where I went, we had 2-month blocks dedicated to inpatient mood, psychosis, geriatric, and C/A (our hospital was somewhat unique).

There is "good" from a prestige perspective. When you say the name, people recognize it. Fortunately, most of the top programs will be "good" in both respects; however, some really just piggyback off of their undergraduate reputation. Hate to name names but consider something like Dartmouth v. Maryland/Sheppard Pratt.

One other reason the first "good" may be worth vying for is when it comes to doing forensic consulting. It's rare that when I'm asked in a deposition, "have you had any experience with X," I can't honestly answer "yes" because my residency training was so broad.

 

[KoolKeith]

I have somewhat of a unique perspective in that I graduated from pharmacy school right at the tail end of the field's hotness and transition into saturation. While I don't think that psych will become saturated to that extent, I am still a little leary of those saying all programs are equal and subsequently struggling to set myself apart from a sea of NPs. Psychiatry is a bit different from pharmacy, but I know for a fact that the reputation of the pharmacy program from which I graduated gave me some opportunities that wouldn't have existed otherwise. I am inclined to believe that the same would be true in this field, but I do value hearing from those who have more experience in psych specifically.

 

[Sushirolls]

Pharm is different that they had their ability to own their own pharmacies gutted. I believed one of the Dakotas is an odd legislative exception. Pharmacy also ruined its field by chasing after the PharmD instead of keeping a bachelors. Essentially pharmacy is entirely owned by Big Box shops and higher student loan debt hand cuffed people to any opportunity they could land.

Psych will always have the private practice out. Doesn't mean you'll make bank, but can eek out a living and have the classic professional autonomy without having to work for Big Box Shops. Psych will likely continue to have ease of transition between the different practices environments IP/OP/CL/ED/Residential/PHP/IOP, etc. Pharmacy was very quick to delineate hospital for the most competitive and retail for everyone else.

 

[KoolKeith]

Pharm is different that they had their ability to own their own pharmacies gutted. I believed one of the Dakotas is an odd legislative exception. Pharmacy also ruined its field by chasing after the PharmD instead of keeping a bachelors. Essentially pharmacy is entirely owned by Big Box shops and higher student loan debt hand cuffed people to any opportunity they could land.

Psych will always have the private practice out. Doesn't mean you'll make bank, but can eek out a living and have the classic professional autonomy without having to work for Big Box Shops. Psych will likely continue to have ease of transition between the different practices environments IP/OP/CL/ED/Residential/PHP/IOP, etc. Pharmacy was very quick to delineate hospital for the most competitive and retail for everyone else.

Exactly, that’s one of more practical aspects that sold me on psych. My concern is that even PP psych will follow a similar trajectory eventually resulting in tiers based on training pedigree and degree (physician vs midlevel)

 

[Sushirolls]

One barrier to the tiering though that I'm seeing is actually being professional, having boundaries, and knowing the nuances medico/legal is bad for Physicians. What I mean by that, an ARNP is more likely to hug a patient in my observation over the years with my small sample size. Psychiatrists won't - we get the training and know not too. ARNPs are more likely to be customer service oriented and prescribe people what they want, and not risk confrontations to educate that certain treatments aren't appropriate. My google reviews are tanking lately because of patients I didn't prescribe stimulants to, or had the audacity to tell them cannabis needs to be stopped, or that they need to get a sleep consult for OSA work up. I recently learned of one ARNP in the area seeing people on the side in small practice from the Big Box Shop, and they just closed up, moved away and ghosted their patients - we know this as patient abandonment - and know medical boards will treat it very, very seriously. But ARNPs, get to play by different rules.

I think the pedigree aspect of people looking into the nuances of training from Psychiatrist will be a much lower level issue even if at a very saturated competitive market. Other things will rise to the surface - male? Female? - or other demographics that people will perceive as resonating with their tribe. Our country is unfolding currently due to the failures of the media and people are regressing from being American, to being XYZ. A colleague I know who is a big Trumplican [female/immigrant/very dark on color spectrum], recently told me how a patient opened up (because of their misguided bias and assumptions of identity politics) stating how they only wanted doctors who are BIPOC and was so glad to have her as her doctor... Sadly this Scat may get to be a new variable everyone gets to navigate in private practice.

 

[dl2dp2]

A colleague I know who is a big Trumplican [female/immigrant/very dark on color spectrum], recently told me how a patient opened up (because of their misguided bias and assumptions of identity politics) stating how they only wanted doctors who are BIPOC and was so glad to have her as her doctor...

lol

 

[hallowmann]

One barrier to the tiering though that I'm seeing is actually being professional, having boundaries, and knowing the nuances medico/legal is bad for Physicians. What I mean by that, an ARNP is more likely to hug a patient in my observation over the years with my small sample size. Psychiatrists won't - we get the training and know not too. ARNPs are more likely to be customer service oriented and prescribe people what they want, and not risk confrontations to educate that certain treatments aren't appropriate. My google reviews are tanking lately because of patients I didn't prescribe stimulants to, or had the audacity to tell them cannabis needs to be stopped, or that they need to get a sleep consult for OSA work up. I recently learned of one ARNP in the area seeing people on the side in small practice from the Big Box Shop, and they just closed up, moved away and ghosted their patients - we know this as patient abandonment - and know medical boards will treat it very, very seriously. But ARNPs, get to play by different rules.

I think the pedigree aspect of people looking into the nuances of training from Psychiatrist will be a much lower level issue even if at a very saturated competitive market. Other things will rise to the surface - male? Female? - or other demographics that people will perceive as resonating with their tribe. Our country is unfolding currently due to the failures of the media and people are regressing from being American, to being XYZ. A colleague I know who is a big Trumplican [female/immigrant/very dark on color spectrum], recently told me how a patient opened up (because of their misguided bias and assumptions of identity politics) stating how they only wanted doctors who are BIPOC and was so glad to have her as her doctor... Sadly this Scat may get to be a new variable everyone gets to navigate in private practice.

People always consciously or unconsciously choose individuals that they identify with in some way to manage their care (if they have that option). This is not a new thing. Its just that as time goes on this is more available to more individual groups because of Physician diversity (relative to the past at least). It's why my PCPs in the 80s were always people that spoke the same native language as my parents growing up. People have always been like this. I don't take offense when my LDS colleague has a bunch of LDS patients, it's the norm and understandable.

 

[Sushirolls]

People always consciously or unconsciously choose individuals that they identify with in some way to manage their care (if they have that option). This is not a new thing. Its just that as time goes on this is more available to more individual groups because of Physician diversity (relative to the past at least). It's why my PCPs in the 80s were always people that spoke the same native language as my parents growing up. People have always been like this. I don't take offense when my LDS colleague has a bunch of LDS patients, it's the norm and understandable.

I choose my doctors based on my bias of their training for those who have openings. What I mean by that, is the usual 'top name' places are what I hold as top name.

When I was younger and didn't know anything I went with who ever was open with quickest access.

 

[PikminOC]

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.

Yea but if these patients supply was cut off they may actually get the correct care

 

[sean80439]

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

very, very few

Confidence does not equal capability.

 

[birchswing]

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.

When you phrase it this way, wouldn't you then have to assume the intent of benzo-first physicians is that they are interested in making their patients get worse?

I assume you don't believe that and probably rather believe they are misinformed, maybe by some niche, rogue troublemaker like . . . Stahl.

 

[Sushirolls]

I recently got a recruiter spam text message, this time not for trying to hire me for the usual slogans, but 'do you know any ARNPs in state XYZ who see children you can refer?'

 

[randomdoc1]

Yea but if these patients supply was cut off they may actually get the correct care

I have too much negative countertransferance. I say let them dig their own grave. Sorry, so tired of the drug seeking and entitlement I've seen cumulatively at this point in the career. lol

 

[Sushirolls]

The solution for entitlement is Medicare for all... possibly. Or it won't even phase people. Just no one will listen or care about voiced demands.

 

[PikminOC]

The solution for entitlement is Medicare for all... possibly. Or it won't even phase people. Just no one will listen or care about voiced demands.

There's no solution to entitlement. Even in jail where controlled subs are not allowed, prisoners keep begging for them