PMHNP in Psychiatry?

[MMADoc]

Hola! M3 soon to be M4 here who is interested in Psychiatry. I have been researching the field/specialty and I wanted to get a generalized opinion on the role of the PMHNP in Psychiatry and how it will affect our role. From my limited understanding it appears as though PMHNP’s have independence and prescribing authority in a multitude of states already and there is a general trend for this to continue to occur in states where they don’t have those rights.

1) Is the PMHNP practice limited by their scope of practice or do they fundamentally do the same job as MDs?

2) How do you foresee the increase in the number of PMHNPs and their increasing level of independence/prescribing authority affecting the role of the Psychiatrist?

Thanks!

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[F0nzie]

Paging Vistaril

 

[heyjack70]

PMHNPs have been given independent practice by legislators due to the huge nursing lobby. PMHNPs leave training about as prepared as a 3rd year medical student who had 3 psych electives. They then get hired somewhere, paid $90K+ and are trained on the job by co-opting the typical good nature of coworker psychiatrists.

 

[prone2xl]

I plan to hire a couple of these one day (contract only of course) so I don't have to pay them benefits. The only problem is ill have to watch them like a hawk bc they will likely be more dangerous than a 3rd year med student and prob know about as much pharmacology as a second year that hasn't yet started studying for step 1 ? Am I right here ️

 

[OldPsychDoc]

I plan to hire a couple of these one day (contract only of course) so I don't have to pay them benefits. The only problem is ill have to watch them like a hawk bc they will likely be more dangerous than a 3rd year med student and prob know about as much pharmacology as a second year that hasn't yet started studying for step 1 ? Am I right here ️

I'm sure they'll be lining up in droves to work for an employer like you...

 

[Nasrudin]

PMHNPs have been given independent practice by legislators due to the huge nursing lobby. PMHNPs leave training about as prepared as a 3rd year medical student who had 3 psych electives. They then get hired somewhere, paid $90K+ and are trained on the job by co-opting the typical good nature of coworker psychiatrists.

I'd even question if they're trained as equivalents of rising 3rd year clerks. Think how much you have to learn in 3rd year from all your clerkships to pass or honor all the shelf exams. I'm quite certain that unless a nurse had a couple of years in a certain field they wouldn't pass a shelf exam in a particular field. And they have no equivalent of measuring progress in terms of benchmarks of knowledge.

I see NP students from of the "top programs in the country" regularly and they shadow nurses and sit in rounds and basically do nothing. They don't have the formal discourse for educating budding clinicians. Seeing and presenting patients and socratic discourse during rounding. They have no semi-independent case load. They're clerkships are like what volunteer premeds do.

From what I've seen. I'm skepitcally open to hearing what the nuts and bolts of their training is. But I think details are important here.

I wouldn't hire an a psychiatric NP unless they were a psychiatric nurse or a psychologist for 5 years and then had solid clinical experience and I lived in an independent practice rights state. And if I did then hire them it's for all the marbles. Full collegial relations as a peer. Because I just don't believe that clinical supervision between to independent clinicans is possible. But I'm about being mastering my own clinical skills not worrying about others. And I certainly will not take responsibility for someone else's half-assed training.

I likely won't be in the hiring position in any case. I'd rather raise the quality of my own services than dilute it for a wider audience. Unless the economics of future practice dictates that we become managers of lesser trained clinicians. I suppose that's possible.

 

[SmallBird]

I'd even question if they're trained as equivalents of rising 3rd year clerks. Think how much you have to learn in 3rd year from all your clerkships to pass or honor all the shelf exams. I'm quite certain that unless a nurse had a couple of years in a certain field they wouldn't pass a shelf exam in a particular field. And they have no equivalent of measuring progress in terms of benchmarks of knowledge.

I see NP students from of the "top programs in the country" regularly and they shadow nurses and sit in rounds and basically do nothing. They don't have the formal discourse for educating budding clinicians. Seeing and presenting patients and socratic discourse during rounding. They have no semi-independent case load. They're clerkships are like what volunteer premeds do.

From what I've seen. I'm skepitcally open to hearing what the nuts and bolts of their training is. But I think details are important here.

I wouldn't hire an a psychiatric NP unless they were a psychiatric nurse or a psychologist for 5 years and then had solid clinical experience and I lived in an independent practice rights state. And if I did then hire them it's for all the marbles. Full collegial relations as a peer. Because I just don't believe that clinical supervision between to independent clinicans is possible. But I'm about being mastering my own clinical skills not worrying about others. And I certainly will not take responsibility for someone else's half-assed training.

I likely won't be in the hiring position in any case. I'd rather raise the quality of my own services than dilute it for a wider audience. Unless the economics of future practice dictates that we become managers of lesser trained clinicians. I suppose that's possible.

I have no insight on the training, but I have been very impressed by some of the recent grads of APRN programs around here. Right after graduation, they are admittedly inexperienced, but seem to be aware of this, are smart, and motivated. Six months in, the APRN's on our inpatient unit and consult service do an excellent job, and I've been quite encourage by the way we can organize ourselves in teams, and not have this be an adversarial experience at all!

 

[Nasrudin]

I have no insight on the training, but I have been very impressed by some of the recent grads of APRN programs around here. Right after graduation, they are admittedly inexperienced, but seem to be aware of this, are smart, and motivated. Six months in, the APRN's on our inpatient unit and consult service do an excellent job, and I've been quite encourage by the way we can organize ourselves in teams, and not have this be an adversarial experience at all!

So....like interns...but paid twice as much...with no future benchmarks of development ahead of them....like for when....say...they start running their own teams. Sounds perfect.

No. This doesn't mean I'm a grumpy bear who doesn't want to play nice with the other kids. Damn our liberal dogmatic training in colleges! We just don't understand the nature of power anymore. We just learn the thousands of ways we should apologize for ourselves.

 

[heyjack70]

I have no insight on the training, but I have been very impressed by some of the recent grads of APRN programs around here. Right after graduation, they are admittedly inexperienced, but seem to be aware of this, are smart, and motivated. Six months in, the APRN's on our inpatient unit and consult service do an excellent job, and I've been quite encourage by the way we can organize ourselves in teams, and not have this be an adversarial experience at all!

Wait until the NPs start pushing to get paid the same "for the same work" as the MD/DO. Wait until you realize your MD salary is lower because NPs are a cheaper alternative "for the same work" for the hospital. It's not adversarial in the sense of doing the work of patient care; who has time to get angry when there are sick patients. But a big part of the NP field is trying to backdoor into being a physician, and this creates inherent friction on the business side.

 

[meriwether]

I can't speak to other programs but the one I am in gives you an RN/BSN after the first three semesters and on top of that the psych track takes six more semesters to complete.

 

[675015]

Six months in, the APRN's on our inpatient unit and consult service do an excellent job, and I've been quite encourage by the way we can organize ourselves in teams, and not have this be an adversarial experience at all!

Aren't you a resident though? So they work well with residents after some time post-training? Doesn't that in and of itself make you nervous? You are at an academic medical center and working with them on a team so they have plenty of supervision. I wouldn't want to send residents who haven't finished their training into the real world so why would we be comfortable sending their equivalents out into the real world?

 

[SmallBird]

Wait until the NPs start pushing to get paid the same "for the same work" as the MD/DO. Wait until you realize your MD salary is lower because NPs are a cheaper alternative "for the same work" for the hospital. It's not adversarial in the sense of doing the work of patient care; who has time to get angry when there are sick patients. But a big part of the NP field is trying to backdoor into being a physician, and this creates inherent friction on the business side.

I mean, that would be problematic. And I would be unhappy if that was to happen. But what the APRN's tell me now, anyway, is that they like having less responsibility, and don't mind that they get paid less for that reason... For example, on an inpatient unit, an APRN is covering 7 to 8 patients, and gets paid a bit more than our residents but significantly less than the attending psychiatrists. They don't have any academic obligations, aren't expected to have any research output, don't have teaching duties, aren't expected to manage staff issues on the unit, etc. They just manage their patients, and discuss challenging cases with the attending. The psych attending would be covering around 8 - 10 of his or her own patients with help from residents, and have additional administrative and academic responsibilities, including being available to advise the APRN. I mean, right now, people seem happy with the set up. I'm not smart enough to predict whether this arrangement is unstable for some reason...

 

[Welles84]

I suppose this is somewhat anecdotal, but today I took care of a patient in my military job who was started on Vilazodone after a "failed" trial of 2 weeks of 10mg of citalopram by his private practice ARNP. I told the patient to go to the VA and see a psychiatrist. I see garbage like this far too often.

 

[heyjack70]

I mean, that would be problematic. And I would be unhappy if that was to happen. But what the APRN's tell me now, anyway, is that they like having less responsibility, and don't mind that they get paid less for that reason... For example, on an inpatient unit, an APRN is covering 7 to 8 patients, and gets paid a bit more than our residents but significantly less than the attending psychiatrists. They don't have any academic obligations, aren't expected to have any research output, don't have teaching duties, aren't expected to manage staff issues on the unit, etc. They just manage their patients, and discuss challenging cases with the attending. The psych attending would be covering around 8 - 10 of his or her own patients with help from residents, and have additional administrative and academic responsibilities, including being available to advise the APRN. I mean, right now, people seem happy with the set up. I'm not smart enough to predict whether this arrangement is unstable for some reason...

Give them a couple years. They will see a few classes of new psychiatry interns coming in and not knowing as much as them on the inpatient unit. Their egos will grow. They'll start arguing that they are functioning better than brand new psych interns so they should be paid like an attending. Or they'll see the draw of starting their own outpatient clinic. They don't need a supervisor because they have "independent practice rights." And hey, they can do therapy because they had a couple classes on group therapy in nursing school, so why not bill for that. Whats the difference, they know as much as an MD. Though they've never really had outpatient supervision, or had taped therapy sessions, or done manualized CBT for PTSD. But they bought Marsha Linehan's book and they understand borderline patients now, so let's do some DBT. Ultimately, there should be a licensing board managing what an NP can and can't do based on their training. It shouldn't be up to the NP to decide they "like having less responsibility" and choose to limit their job, because there are plenty of ambitious people who will have an NP degree and make poorly informed decisions, not knowing what they don't know, and will be providing inadequate care. The problem is NPs are managed by the nursing board, not the medical board, and the nursing board is never going to do anything to limit what an NP can do. One of the talking points is NPs provide better care than MDs. Seriously?? How can anybody make that claim? Oh, they've got a nursing-funded study backing up patient satisfaction being higher with NPs. Sounds like a watertight argument to me.

The problem is that it should not be the NP deciding they want less responsibility. The NP should simply have less responsibility because they are filling a specific role in the health care team which is limited based on significantly less training. But that's not how it works in the real world, unfortunately.

Don't get me wrong. There are good NPs. But when fresh out of school they are not ready to work. It takes months to get them trained to function in whatever job they take. And if the job right out of school is an outpatient clinic, they are not going to be able to switch into a hospital without several more months of on the job training. All the while making 2x what a resident earns.

 

[heyjack70]

I suppose this is somewhat anecdotal, but today I took care of a patient in my military job who was started on Vilazodone after a "failed" trial of 2 weeks of 10mg of citalopram by his private practice ARNP. I told the patient to go to the VA and see a psychiatrist. I see garbage like this far too often.

I'm seeing ARNPs starting Brintellix as a first antidepressant because there are samples in the clinic.

 

[MMADoc]

On the topic of PMHNP and outpatient psych services, is anyone aware of what additional training requirements they would require outside of obtaining their license before the could open up their own outpatient psych practice? Does anyone believe that the role of the psychiatrist will become more focused on inpatient treatment while PMHNPs cover outpatient psych treatment?

 

[MacDonaldTriad]

I'm seeing ARNPs starting Brintellix as a first antidepressant because there are samples in the clinic.

I'm starting to see a lot of psychiatrists start Brintellix as a first antidepressant because there are samples in the clinic. Why should they be any better than us?

 

[Shikima]

I think it's an unsustainable model and IMO it's better to use medications on the $4 plan to initially start off with.

 

[F0nzie]

What the hell is Brintellix? Go NPs!

 

[MacDonaldTriad]

It is touted as a new super duper SSRI, but probably just an SSRI. Just what we need! SSRIs revolutionized psychiatry in 1985, but 30 years later it is hard to treat a patient that hasn't been tried on them.

 

[F0nzie]

It is touted as a new super duper SSRI, but probably just an SSRI. Just what we need! SSRIs revolutionized psychiatry in 1985, but 30 years later it is hard to treat a patient that hasn't been tried on them.

Also in 1985:

 

[erg923]

Also in 1985:

Are you implying phil collins music is a result of a (untreated?) mental disorder? How dare you, good sir...

 

[Doctor Bagel]

Don't get me wrong. There are good NPs. But when fresh out of school they are not ready to work. It takes months to get them trained to function in whatever job they take. And if the job right out of school is an outpatient clinic, they are not going to be able to switch into a hospital without several more months of on the job training. All the while making 2x what a resident earns.

This is true. What is also possibly true (albeit depressing) is that they might catch up with us in whatever area they are working in and honestly be as competent as we are if they get good on the job training while yes earning twice as much as us. While we spend years in classrooms, the substance of our training is on the job stuff. The quality of their on the job training probably varies, though -- in some spots, I think they get very little. The smart, self-aware ones probably seek out jobs with more supervision and support. The less self-aware ones might not. Of course in some ways you can say the same thing about psychiatrists. We have some minimum of training, but it's not always equivalent. I'll say I have zero competency in doing CBT in PTSD even with being board-certified.

 

[sunlioness]

I have no formal DBT training, but I also bought Linehan's book. Perhaps I should give it a whirl.

Also taped therapy sessions sound horrible. I'm glad I never had to do that either. I'm sure it's a valuable tool, but ugh. I did have supervisors observe through one way glass.

 

[heyjack70]

I have no formal DBT training, but I also bought Linehan's book. Perhaps I should give it a whirl.

Also taped therapy sessions sound horrible. I'm glad I never had to do that either. I'm sure it's a valuable tool, but ugh. I did have supervisors observe through one way glass.

Taped or otherwise observed therapy is invaluable.

 

[Nasrudin]

This is another case of some of us being conspicuously incognizant of what processes have forged us. We didn't start where we are now. We crawled inch by inch the whole way. Learning and forgetting and learning again. Over and over. Tests on a legion of basic medical science that would crumple all but the most industrious NP's. Just to get to square one of psych training. Such that the substrate is lean, information digesting machines.

Then we enter well-tested and proven guild system, supported by government funding, where tens of thousands of hours of clinical wisdom are passed down from clinician to clinician in juicy, applicable morsels for our young clinical minds to fit into situations right in front of us. Wherein, also, we move ever so gradually towards the deep end of the pool. Interspersed with periods of pure unwanted independence by necessity on call shifts. We get constantly stimulated, encouraged, and inspired by our senior clinicians. All along the way we read into the night at times, curious about a clinical problem, getting ready for presenting a case, or a topic, or an article. We see our peers stiving and improving and we have a culture that tells us to study, even after long hours, because that's how we f'n roll. And if you don't want to suck you don't take the short cut home.

You think for one second you get the product of all your colleagues from a system that makes mincemeat of clinical tradition in favor of "on the job training"?! This isn't f'n McDonald's. You don't jump in on the line and start making french fries. This is clinical work. It's sophisticated and dangerous work.

I've learned more negotiating and management skill as an intern working with the hostile natives of New York nursing unions with their particularly onerous and overmedicating-anything-that-moves psychiatric constituency than I have in my 40 years of working at dozens of other jobs. What we do requires a complicated skill set. And it doesn't come cheaply.

I'm tired of the cynics, even though I am one in other spheres, and self-hating bottom feeding urchins around here making a "f@ck you Dad!" I'm joining a punk band out of our system of training.

Yes, we've chosen a field where you can skate by and suck and most people won't understand that you suck. But the last thing we need to do is make that easier. Which if they stand for anything, NP's make one thing f'n clear between the lines of propagandized, grandiose BS--They make it easier to suck.

 

[675151]

I suppose I'm wandering into the proverbial feces pile, but I concede that your skepticisms are sound. Myself, I spent a decade in law enforcement, with separate higher education, before becoming intrigued by mental health, and as I began to research the avenues of mental health practice I realized a couple of things. 1) I was not at a point in life to stop everything and return to school thus no PhDs or MDs, etc. 2) There wasn't a PA school in my region which is actually what I wanted. Having said that, I made some inquiries and was readily accepted into a new bachelor's in nursing program (without ever formally applying) at the local state U., and off I went having found that RNs can become NPs and NPs can specialize in mental health. I wrongly assumed that nursing was more scientific, sound, and thoughtful than it really is, and I am frankly embarrassed to be a nurse at times. The same might be said of being a NP as another local state U. supplied that portion of my training. In reality, NP training is rather light, and I have pounded the drum that the curriculum needs to be augmented since first attending school.

Nonetheless, nursing holds onto its vapid nursing theories, philosophies, and peculiar nursing diagnoses for reasons most practicing nurses don't understand or agree with. The NP crowd doesn't really buy into any of it, but somewhere along the way we had to learn that end of nursing. I'm at a point now where I can't stop, and every step of the way has required that I build my own, personal curriculum replete with the many areas that NP school did not offer - namely anything scientific. Sure, it did fine covering DSM diagnoses and the "usual" medications and their mechanisms of actions, but the level is rather base. Had I known many of the things I now know I would've likely chosen a different path, however, I can either not enter into practice or supplement my knowledge. I choose the latter over the former.

With respect to job tasks, I am even more poorly trained in psychotherapy, yet I have learned that I do not wish to be a therapist so I am content with this at this juncture. I have also learned that I don't care beans about working in a hospital setting but for reasons other than what you may think. After becoming a RN, I managed a jail clinic for a while and moved onto the emergency department of an urban hospital. Both were good learning experiences, but I don't like being in a hospital (or working as a RN). Is my scope limited because of this? Absolutely, and I'm aware of that. I focus on outpatient experiences, and I have been fortunate since day one that I've been able to take the lead in evaluating patients and recommending treatment rather than passively sitting in a corner watching as many of my classmates likely have. Then again, I'm not a passive man, but without that element of my education I likely would be remiss in present patient encounters.

Unfortunately, for other NPs, I see the perpetual tirade of disparaging remarks made by physicians. It saddens me that so many passive nurses are injured by such commentary. Thankfully my previous profession has yielded quite the emotional callus so I can endure. However, I'm puzzled. NPs are not going away, and I completely understand the veritable turf war being waged, and I'm sure a very small minority of physicians are actually concerned for patient outcomes. Rather than berating NPs why not take action to change what they learn? Their instruction is governed by policy, and like it or not the physician community still carries quite a bit of clout. If you find NPs to be dimwitted or ill prepared use your professional bodies to correct this. Most NPs I know wish their professional preparation had been better, and the ones who make good clinicians are only good because they chose to be. We must realize this is true of anyone - even psychiatrists. If you're good at what you do, your schooling and training represents only a small portion of your character and ability.

To answer the OP, I don't feel your role as a burgeoning psychiatrist will be changed by the presence of NPs. I think a need for mental health providers coupled with an economic need will maintain the role of the NP (and PA). With respect to treatment, scope, etc. In my state, NPs (and PAs) may not presently prescribe Schedule II medications, yet that may change, and neither may place a patient on an emergency hold. Beyond that, there is little difference in practice patterns or populations - leaving out the comparison of who has the bigger caduceus.

 

[heyjack70]

I suppose I'm wandering into the proverbial feces pile, but I concede that your skepticisms are sound. Myself, I spent a decade in law enforcement, with separate higher education, before becoming intrigued by mental health, and as I began to research the avenues of mental health practice I realized a couple of things. 1) I was not at a point in life to stop everything and return to school thus no PhDs or MDs, etc. 2) There wasn't a PA school in my region which is actually what I wanted. Having said that, I made some inquiries and was readily accepted into a new bachelor's in nursing program (without ever formally applying) at the local state U., and off I went having found that RNs can become NPs and NPs can specialize in mental health. I wrongly assumed that nursing was more scientific, sound, and thoughtful than it really is, and I am frankly embarrassed to be a nurse at times. The same might be said of being a NP as another local state U. supplied that portion of my training. In reality, NP training is rather light, and I have pounded the drum that the curriculum needs to be augmented since first attending school.

Nonetheless, nursing holds onto its vapid nursing theories, philosophies, and peculiar nursing diagnoses for reasons most practicing nurses don't understand or agree with. The NP crowd doesn't really buy into any of it, but somewhere along the way we had to learn that end of nursing. I'm at a point now where I can't stop, and every step of the way has required that I build my own, personal curriculum replete with the many areas that NP school did not offer - namely anything scientific. Sure, it did fine covering DSM diagnoses and the "usual" medications and their mechanisms of actions, but the level is rather base. Had I known many of the things I now know I would've likely chosen a different path, however, I can either not enter into practice or supplement my knowledge. I choose the latter over the former.

With respect to job tasks, I am even more poorly trained in psychotherapy, yet I have learned that I do not wish to be a therapist so I am content with this at this juncture. I have also learned that I don't care beans about working in a hospital setting but for reasons other than what you may think. After becoming a RN, I managed a jail clinic for a while and moved onto the emergency department of an urban hospital. Both were good learning experiences, but I don't like being in a hospital (or working as a RN). Is my scope limited because of this? Absolutely, and I'm aware of that. I focus on outpatient experiences, and I have been fortunate since day one that I've been able to take the lead in evaluating patients and recommending treatment rather than passively sitting in a corner watching as many of my classmates likely have. Then again, I'm not a passive man, but without that element of my education I likely would be remiss in present patient encounters.

Unfortunately, for other NPs, I see the perpetual tirade of disparaging remarks made by physicians. It saddens me that so many passive nurses are injured by such commentary. Thankfully my previous profession has yielded quite the emotional callus so I can endure. However, I'm puzzled. NPs are not going away, and I completely understand the veritable turf war being waged, and I'm sure a very small minority of physicians are actually concerned for patient outcomes. Rather than berating NPs why not take action to change what they learn? Their instruction is governed by policy, and like it or not the physician community still carries quite a bit of clout. If you find NPs to be dimwitted or ill prepared use your professional bodies to correct this. Most NPs I know wish their professional preparation had been better, and the ones who make good clinicians are only good because they chose to be. We must realize this is true of anyone - even psychiatrists. If you're good at what you do, your schooling and training represents only a small portion of your character and ability.

To answer the OP, I don't feel your role as a burgeoning psychiatrist will be changed by the presence of NPs. I think a need for mental health providers coupled with an economic need will maintain the role of the NP (and PA). With respect to treatment, scope, etc. In my state, NPs (and PAs) may not presently prescribe Schedule II medications, yet that may change, and neither may place a patient on an emergency hold. Beyond that, there is little difference in practice patterns or populations - leaving out the comparison of who has the bigger caduceus.

Perhaps NP school should be expanded to 4 years. Then a program of supervised specialty training for, oh, let's say 4 more years, and then they would be ready to practice. Or they could just go to medical school. The fact is that if NP school was tougher, the schools would be failing half the students.

 

[heyjack70]

Tougher and longer are both good by me. Failing half is good by me.

I've become acquainted with a series of medical schools condensing to a three year program, and I think three years (even without summer sessions) would be sufficient training for PMHNPs. I can't speak for residency training breadth (and don't care to), but I wish the NP program followed a similar model of generalized education with post-graduate training. I have no interests in examining genitals or the surgical abdomen, but I would welcome with open arms added training in such fields as neurology, IM, peds, etc.

My master's program has spanned three years of full-time study, however, I'm not comparing, and I agree wholeheartedly that it was deficient. I would have loved to have had a more enriched course of instruction. My personal preference was in having the ability to earn a full-time wage and hang on to health benefits and retirement planning while in graduate school. I don't have the answer to what would make NP training best, but we all know what will make it better. I'm not making a comparison so much as I'm seeking an improvement.

NPs need residency training. That's the bottom line. They are coming out of school ill prepared for independent practice but are doing it anyways because the nurse lobby has pushed to open the flood gates. I think without a residency, no NP should be practicing without supervision. Unfortunately nobody wants to strip away their ability for independent practice and institute such a program.

 

[675151]

Again, I'm not opposed to residency training and do see a need. Most states are still collaborative. Mine is. I personally didn't come into the field in search of independent practice but merely the opportunity to practice.

 

[Armadillos]

I suppose I'm wandering into the proverbial feces pile, but I concede that your skepticisms are sound. Myself, I spent a decade in law enforcement, with separate higher education, before becoming intrigued by mental health, and as I began to research the avenues of mental health practice I realized a couple of things. 1) I was not at a point in life to stop everything and return to school thus no PhDs or MDs, etc..

This is the huge problem for me and a lot of of other physicians. Im 100% in support of the traditional NP model, where you have people who went to nursing school to be nurses, and then after a decade or more of nursing the best of the best wanted opportunities to move into more advanced roles. This makes 1o0% sense and is reasonable to me.

But now the system has been hijacked as an express route to attempting to practice in a physician type role with dramatically decreased training. The fact that you don't have to put your life on hold to get a NP should be a red flag, not a selling point. It makes sense to have an alternate route available to long time experienced nurses, but as it is now its a reckless situation. IMO NP programs should require you to practice as a bachelors level RN for at least 6 years before starting the NP program then require a 1 year internship afterwards. Getting a MD should be the quickest route to practicing in that capacity, the NP should be the mid-career nursing route, not the route for those who are jumping ship from other fields and naive to the practice of medicine.

(This is coming from someone whose PCP is a NP, but she was an ICU nurse for over a decade and now has been an NP for 15 years, I obviously have no problem with that)

 

[Shikima]

This is the huge problem for me and a lot of of other physicians. Im 100% in support of the traditional NP model, where you have people who went to nursing school to be nurses, and then after a decade or more of nursing the best of the best wanted opportunities to move into more advanced roles. This makes 1o0% sense and is reasonable to me.

But now the system has been hijacked as an express route to attempting to practice in a physician type role with dramatically decreased training. The fact that you don't have to put your life on hold to get a NP should be a red flag, not a selling point. It makes sense to have an alternate route available to long time experienced nurses, but as it is now its a reckless situation. IMO NP programs should require you to practice as a bachelors level RN for at least 6 years before starting the NP program then require a 1 year internship afterwards. Getting a MD should be the quickest route to practicing in that capacity, the NP should be the mid-career nursing route, not the route for those who are jumping ship from other fields and naive to the practice of medicine.

(This is coming from someone whose PCP is a NP, but she was an ICU nurse for over a decade and now has been an NP for 15 years, I obviously have no problem with that)

CRNAs need a dedicated amount of time in the ICU prior to applying this kind of schooling with an intensive didactic and clinical schedule. However, I do believe nursing got it wrong when you need to "write a paper" in lieu of clinical experiences.

 

[Nasrudin]

Psych NP guy,

It takes some nuts to come in here and lay it out honest like you are. You're obviously not the sort of colleague any of us would mind.

Nevertheless I think it's necessary to counter your claim of pervasive disparaging of NP's--as it we're all the sort who like to kick 5 year olds in the shins for fun--by referring you to your own ideas about what you want or don't want to do--ie complete a surgery rotation, or learn basic therapy modalities, et al.

Training is not about what you want to do. You train to do the job by being forced into uncomfortatble situations over and over again. The right sort of situations that we get put in serve a purpose. Brand new NP's being left to figure it out on the job with a hodge podge mix of unorganized supervision is the wrong kind of uncomfortable that serves no purpose. Comfort in the latter means being comfortable not knowing what you're doing. In the former it means working gradually towards progressively more sophisticated and updated versions of your self with examples of what to reach for and occasionally to avoid that you figure out in a proper training milieu.

Comfort and convenience doesn't cut it as training ethic.

Also, how dare you fault us for the compromises your constituency makes while simultaneously shoving legislation through state legislatures like bulldogs while simultaneously acting like wounded puppies in front of the public with phrases like "pervasive disparaging of NP's" that roll of the subconscious of Mother Nurse culture effortlessly.

How dare you sir. Your integrity is your own responsibility. I could never settle for going the nursing or pa route. So I made the sacrifice. If you didn't make the sacrifice but achieve parity through disingenuous complicity with your political bodies expect my professional, but not personal, disrespect unless your an old school NP and/or you've proved it otherwise.

 

[Armadillos]

I understand your concerns. Thank you.

I've worked ICU and never dealt with anything primary care related. Interesting path.

It's a statistical filter more than the actual experience, most crappy nurses can't get and hold an ICU job for a decade. That being said the more time you spend working with really sick patients the better your going to be in general IMO. All the best outpatient family docs I know did their residencies at places where they spent a lot of time in ICUs.

 

[PikminOC]

I'm seeing ARNPs starting Brintellix as a first antidepressant because there are samples in the clinic.

My rep told me about one who is taking her brintellix samples herself...

 

[PikminOC]

This is the huge problem for me and a lot of of other physicians. Im 100% in support of the traditional NP model, where you have people who went to nursing school to be nurses, and then after a decade or more of nursing the best of the best wanted opportunities to move into more advanced roles. This makes 1o0% sense and is reasonable to me.

But now the system has been hijacked as an express route to attempting to practice in a physician type role with dramatically decreased training. The fact that you don't have to put your life on hold to get a NP should be a red flag, not a selling point. It makes sense to have an alternate route available to long time experienced nurses, but as it is now its a reckless situation. IMO NP programs should require you to practice as a bachelors level RN for at least 6 years before starting the NP program then require a 1 year internship afterwards. Getting a MD should be the quickest route to practicing in that capacity, the NP should be the mid-career nursing route, not the route for those who are jumping ship from other fields and naive to the practice of medicine.

(This is coming from someone whose PCP is a NP, but she was an ICU nurse for over a decade and now has been an NP for 15 years, I obviously have no problem with that)

Diploma mills abound!

 

[Nasrudin]

Nasrudin, thank you for your candor.

With respect to a couple of your points, I think perhaps you allowed my remarks to cut too deeply. I fully support physicians, or their political bodies, influencing the training of NPs. Granted, we can both be assured that NPs aren't going away, however, nursing organizations, from lobbying groups down to academic accrediting bodies, need more awareness of the reality. The focus of education and training in RN programs are base, and nursing schools are trying to sell something opposite. That of NP programs is more tailored to peculiar, academic theorems rather than clinical practice. All NPs enter NP training wanting to become well trained clinically, yet most of the leave with nothing but slander for their respective programs. The good NPs then become good because they become autodidacts. What wants me to beat my head against the wall are the coupling of physicians and NP groups who merely sit around and talk about how crappy it was or is and do nothing about it. Even as a student, I was quick to tell faculty that their curriculum was full of holes, and most were already aware and complacent. For example, there was nothing in our course offerings that did little but mention neurophysiology, neural pathways, etc. I felt there was merit in learning those overlooked aspects. We could backtrack even further. For example, I was never required to take biochemistry at any point in my training, and I recently began reading a text on medical biochemistry. It's wonderful, and I think "why didn't we have to take this before physiology or pharmacology?" Those types of what I'll call "underpinnings" are absent. Now, I want to reread the latter after the former.

The second point lies in parity. I've never been the guy who said I'm going to be equal in scope or understanding. I have no problem asking a question, but I have even less problem with researching an answer myself. I don't feel as if I settled for anything. I did not want to go to medical school (and still don't) but not because it's complicated. I merely don't want to lock away another segment of my life, and if you wish to criticize me for that then that's ok. I'll never hold it against you because it's a personal belief. I commend you for making the sacrifice that you speak of. You decided what you wanted to do and did it. When I first left college I decided I wanted to enter law enforcement and did so, and had a lot of sacrifices, but I thoroughly loved it (and still miss it). I did it with a great deal of efficacy, but over the years I encountered a great need for mental health. In time, I chose to enter the mental health field. I understand what you say about comfort and convenience, and I think you're laying it on a little thick. Then again, that's ok. I'm sure you feel that to be anywhere equal one must "pay their dues." In many respects, I feel the same way, but as I said I would have never left my first profession if I had to remand my self to being a school boy again and doing nothing but going to class and studying.

I'm not quite sure what set you off about my not wanting to complete a surgery rotation, and I would if I had to. The fact is I didn't have to that or a myriad of other things, and I'm ok with that. If I find in the future, I need a more advanced knowledge of that area then I'll begin to study it. As it happens, my years in the ER provided some breadth with respect to some things of a surgical nature, but that's neither here nor there. I'm clearly not a surgical diagnostician. I want to mention therapy. I'm not uncomfortable with it, but yes you're correct in your interpretation of that not being where I want to be in practice presently. I did not mean to imply that I did not want to learn it, because I do, but my training was grossly deficient in that, and as you know NPs are not hired to be therapists thus the likelihood of me becoming a well polished therapist is mostly nil. I wish I'd had more coverage in it.

Finally, I am not a member of any nursing lobbying groups or what I think of as "pot stirrers." I don't believe in them in their present state. Frankly, I don't care if NPs are independent or not. I don't feel they're quite as successful at lobbying as you apparently do, but I will only help them when we have mutually aligned values. I don't care if a NP has ever worked a day as a RN. I feel, however, and preach continuously, that NP school needs a major overhaul as does what we'll call RN school. They're both crap and no amount of expert APA paper formatting is going to make up for clinical experience. I could go on all day about my opinions, but that's all they are. I try to share them with people who can do something positive for nursing, but in my region those are few and far between. Like I've told my wife, I never went to the nursing indoctrination class. I'm not really a nurse. I'm just a guy trying to learn and do something that's going to help out a little bit.

I was half joking with the how dare yous. I don't feel insulted by anything you're saying. Quite the opposite.

You and me both on the indoctrination thing.

 

[Sunny in Psych]

I see skeptism, and I don't blame students for this. They are new to it, although NPs have been around for over 50 years. With that said, I hope you will think of your PMHNPs on the team as colleagues. This is not a turf war as there are plentry of patients to go around. I agree, a couple years experience prior to working independently gives PMHNPs the experience they need to work independently. With that said, I've been practicing as a PMHNP (forensically trained) for 14 years. I own a private practice in TX. In my practice, I provide care
To over 1200 mentally ill patients, about 60% Medicaid, so they are very sick. I am part if the team in Corpus Christi, referred to by PCPs, psych hospitals, and numerous other mental health facilities. The psychiatrists refer their overflow and inpatient discharges to me. We are colleagues and friends, with much respect for one another. As for pay, I am reimbursed approx 85% of MD reimbursements by insurance companies. I would never take what some of you mention as "good enough" pay. I AM doing the same job. I am the first and only independent PMHNP practice in town, and am thankful that the old, seasoned psychiatrists took me in with open arms into the community.

Hola! M3 soon to be M4 here who is interested in Psychiatry. I have been researching the field/specialty and I wanted to get a generalized opinion on the role of the PMHNP in Psychiatry and how it will affect our role. From my limited understanding it appears as though PMHNP’s have independence and prescribing authority in a multitude of states already and there is a general trend for this to continue to occur in states where they don’t have those rights.

1) Is the PMHNP practice limited by their scope of practice or do they fundamentally do the same job as MDs?

2) How do you foresee the increase in the number of PMHNPs and their increasing level of independence/prescribing authority affecting the role of the Psychiatrist?

Thanks!

 

[leslieknope2]

Nvm!

 

[Sunny in Psych]

I plan to hire a couple of these one day (contract only of course) so I don't have to pay them benefits. The only problem is ill have to watch them like a hawk bc they will likely be more dangerous than a 3rd year med student and prob know about as much pharmacology as a second year that hasn't yet started studying for step 1 ? Am I right here ️

Most of us are pretty savvy about what we are worth. I would never take a 1099 job for less than $100/hr. With that said, I own a private practice, so many of us choose not to work for a psychiatrist.

 

[Sunny in Psych]

Wait until the NPs start pushing to get paid the same "for the same work" as the MD/DO. Wait until you realize your MD salary is lower because NPs are a cheaper alternative "for the same work" for the hospital. It's not adversarial in the sense of doing the work of patient care; who has time to get angry when there are sick patients. But a big part of the NP field is trying to backdoor into being a physician, and this creates inherent friction on the business side.

Where you are wrong is that we are not trying to be physicians. We are advanced practice nurses. Trained and educated to provide patient care independently. Study after study shows our outcomes equal to physicians' (sometimes better). Before you go on any rampant about NPs, who have been around for over 50 years, be sure to educate yourself about them .

 

[Sunny in Psych]

What the hell is Brintellix? Go NPs!

I hope you know it's "Trintellix".

 

[WisNeuro]

Don't we usually keep these discussions confined to the pre-allo forum?>

 

[Sunny in Psych]

Don't we usually keep these discussions confined to the pre-allo forum?>

Just started on here today. And on my phone, not easy to follow.

 

[WisNeuro]

I hope you know it's "Trintellix".

It actually used to be called Brintellix. He did not mis-type that.

 

[Sunny in Psych]

It actually used to be called Brintellix. He did not mis-type that.

I'm aware of that. It was a little snarky comment from a PMHNP who has been around for a long time.

 

[michaelrack]

I hope you know it's "Trintellix".

for some of us nostalgic types, it will always be "Brintellix"

 

[WisNeuro]

I'm aware of that. It was a little snarky comment from a PMHNP who has been around for a long time.

Seemed to have a different tone. Tough to tell on the interwebz.

 

[st2205]

With that said, I've been practicing as a PMHNP (forensically trained) for 14 years.

What does this mean?

 

[splik]

What does this mean?

served time in a federal prison for medicare fraud perhaps?