Should Psychiatrists be concerned about future encroachment from NPs, PAs, PsyDs?

[Doctor Bagel]

I'm not worried about encroachment with the shortages everywhere, and I mean shortages.

Shortages end. We're looking down the road for 20+ years, so how the market is today says very little about how it will be in the future. A term called "greedy associates" became a thing in the 1990s because new hire lawyers were getting paid so much money. Look at how they're doing now.

---

Members don't see this ad.

 

[notdeadyet]

Shortages end. We're looking down the road for 20+ years, so how the market is today says very little about how it will be in the future. A term called "greedy associates" became a thing in the 1990s because new hire lawyers were getting paid so much money. Look at how they're doing now.

There's a big difference and that is GME.

Law went to the crapper because law schools exploded in number and size. They could keep doing so because they kept earning tuition.

Allopathic medical schools have been expanding, but at a slower rate. Osteopathic schools have been growing quicker, particularly with the for-profit schools.

But GME hasn't increased by much and when they do increase, they do it slowly and intelligently because this is how they protect their income. You may get a glut of medical students, but you won't get a glut of residency trained docs. This is why you'll see a continuing pinch edging out IMGs/FMGs. Will it get to the point that it will happen to DOs? Maybe two coming out of the newer and for-profit schools.

But I don't see a time when we'll be flooded with psychiatrists, dermatologists, and the like.

 

[notdeadyet]

If folks are really worried about encroachment, the solution is simple: offer up something your competitors can't.

The days of stocking a practice of cash-payment medication management patients on an SSRI is likely drawing to a close and probably should be. But it isn't going to be hard in too many markets to distinguish yourself from NPs and PAs. If you can't do that, you need to rethink what you're doing. If your training is any good and if you're any good, you can do lots of things those competitors can't.

 

[Doctor Bagel]

There's a big difference and that is GME.

Law went to the crapper because law schools exploded in number and size. They could keep doing so because they kept earning tuition.

Allopathic medical schools have been expanding, but at a slower rate. Osteopathic schools have been growing quicker, particularly with the for-profit schools.

But GME hasn't increased by much and when they do increase, they do it slowly and intelligently because this is how they protect their income. You may get a glut of medical students, but you won't get a glut of residency trained docs. This is why you'll see a continuing pinch edging out IMGs/FMGs. Will it get to the point that it will happen to DOs? Maybe two coming out of the newer and for-profit schools.

But I don't see a time when we'll be flooded with psychiatrists, dermatologists, and the like.

Tell that to radiologists and pathologists who feel like training spots have increased enough that their income really is diving. Also, GME doesn't protect us from other providers who say they can do exactly the same things as us. As far as I know, there's no actual limits on NP training, and more and more programs are popping up.

 

[WalterDonnie]

I heard from a law buddy that lawsuits against NPs and PAs were up 30% last year from the year before. So basically the lawyers are starting to smell blood. Eventually patients won't want to see them and places won't want to hire them.

 

[WalterDonnie]

"Have you, or someone you know, fell victim to an adverse medical outcome in the hands of a mid-level provider? Better call Saul"

 

[Pathman1000]

As sad as it is to say, the future of healthcare will be dictated by cost, not quality. Is the patient going to pay to see a psychiatrist or will they stand in line for 15 minutes outside a CVS to see the discount noctor? They can get their handful of prescriptions through the drive-through while they're at it...

Enjoy it while you can. The future belongs to the mid-levels.

 

[WalterDonnie]

As sad as it is to say, the future of healthcare will be dictated by cost, not quality. Is the patient going to pay to see a psychiatrist or will they stand in line for 15 minutes outside a CVS to see the discount noctor? They can get their handful of prescriptions through the drive-through while they're at it...

Enjoy it while you can. The future belongs to the mid-levels.

I don't believe that. Just look at how entitled Medicaid patients are. Once word gets out that the quality of care is substantially less with a mid-level provider do you really think they are going to choose an NP? Nevermind private insurance patients. At this point most patients don't really have any idea about the NP/PA vs. MD/DO situation. but once they become educated consumers they will make educated decisions.

 

[Pathman1000]

The noctors have that covered. They'll just use their massive lobby to selflessly promote how compassionate and hardworking they are compared to the greedy MDs driving Jaguars and screwing patients over for 400k salaries. Then they'll pump out a few "peer-reviewed" articles about how they're not only more cost-effective but also just as competant as you are. If you don't believe me, check out the anesthesia forum to see the monster they let out of the box with the CRNAs.

 

[WalterDonnie]

Ya i hear that. I guess I'm just assuming the lawyers will parse it out. The lawsuits will speak for themselves. If CRNAs kill enough people it will get into the media and the whole midlevel vs dr discussion will happen publicly.

 

[WalterDonnie]

I feel like once the public knows what a CRNA is they would always request an anesthesiologist to do their surgery. They just don't even know at this point. All they know is someone comes up and sais, "ill be your anesthesia provider today".

 

[Leo Aquarius]

Prescribing rights is not a threat. Primary doctors already prescribe antidepressants all across this fine land. When they don't work, patients look for the more expertise provider, in this case the psychiatrist. When NPs match the abilities of primary care doctors, we will still be in demand because human nature will always want "the best".

 

[Shikima]

The noctors have that covered. They'll just use their massive lobby to selflessly promote how compassionate and hardworking they are compared to the greedy MDs driving Jaguars and screwing patients over for 400k salaries. Then they'll pump out a few "peer-reviewed" articles about how they're not only more cost-effective but also just as competant as you are. If you don't believe me, check out the anesthesia forum to see the monster they let out of the box with the CRNAs.

I knew a CRNA who once said that he was in every way equal to a MD and demanded the same respect.

 

[sunlioness]

And NPs just out of training are being hired for really tough jobs, like jumping into busy community clinics or leading forensic ACT teams (true example). As it is, I feel like there's a ton of stuff I still need to learn having just completed residency and a fellowship. I can't imagine going straight out of school into jobs like this, treating the sickest people we have.

It sounds horrific. I was just thinking the other day how people always say that community mental health is the best job out of residency because the learning curve is so steep. I can't begin to say how much I disagree with that. I'm doing it now and it's fine. But if I had done this fresh out of training, I'd have spent the bulk of every day hiding under my desk and shaking.


Sent from my iPhone using Tapatalk

 

[Dharma]

Slippery slopes!

 

[Jorje286]

There's a big difference and that is GME.

Law went to the crapper because law schools exploded in number and size. They could keep doing so because they kept earning tuition.

Allopathic medical schools have been expanding, but at a slower rate. Osteopathic schools have been growing quicker, particularly with the for-profit schools.

But GME hasn't increased by much and when they do increase, they do it slowly and intelligently because this is how they protect their income. You may get a glut of medical students, but you won't get a glut of residency trained docs. This is why you'll see a continuing pinch edging out IMGs/FMGs. Will it get to the point that it will happen to DOs? Maybe two coming out of the newer and for-profit schools.

But I don't see a time when we'll be flooded with psychiatrists, dermatologists, and the like.

Yes, and if you keep the lid tight entirely for profit making then somebody else would come up to fill the gap. I'm just saying, medical professionals aren't entirely victims here.

 

[Doctor Bagel]

Yes, and if you keep the lid tight entirely for profit making then somebody else would come up to fill the gap. I'm just saying, medical professionals aren't entirely victims here.

Very true. Having a shortage benefits us, but there was this catch. Interestingly working in areas that have really profound shortages, it seems like everyone has just routed around the psychiatrists, assuming all the stuff we do is done by NPs and PCPs.

 

[WingedOx]

Very true. Having a shortage benefits us, but there was this catch. Interestingly working in areas that have really profound shortages, it seems like everyone has just routed around the psychiatrists, assuming all the stuff we do is done by NPs and PCPs.

Yup. Derm seems like the current manifest destiny for the NPs. I weep for patient care but not for the profession that seemed content with a perpetual shortage of physicians over the years and is now learning about the law of unintended consequences.

 

[F0nzie]

If folks are really worried about encroachment, the solution is simple: offer up something your competitors can't.

The days of stocking a practice of cash-payment medication management patients on an SSRI is likely drawing to a close and probably should be. But it isn't going to be hard in too many markets to distinguish yourself from NPs and PAs. If you can't do that, you need to rethink what you're doing. If your training is any good and if you're any good, you can do lots of things those competitors can't.

Agreed. And great advice. Although I don't think most docs have the mindset of distinguishing themselves from competitors aside from having 12 years of post high school education.

 

[WingedOx]

but once they become educated consumers they will make educated decisions.

don't count on it.

 

[Rogue Penguin]

Yes, and if you keep the lid tight entirely for profit making then somebody else would come up to fill the gap. I'm just saying, medical professionals aren't entirely victims here.

My $400k of debt combined with all this talk of doctors losing income is making me feel like a victim.

 

[Throwaway2016]

I think the craziest thing I know about PMHNPs is the length of their training before they could be potentially treating patients unsupervised. Without naming names, I know about a "top" PMHNP program on the east coast that accepts some applicants with a bachelors but no RN background or other healthcare experience. In this 3 year program these individuals receive their RN license and their mental health training. I am sure the more experienced members can chime in but I don't see what would stop these people from heading to one of the west coast states with full independence/prescribing and setting up their shingles after they graduate. What happened to the idea that NPs were supposed to be for experienced nurses with years of healthcare exposure who wanted to extend their scope?

 

[notdeadyet]

Although I don't think most docs have the mindset of distinguishing themselves from competitors aside from having 12 years of post high school education.

Yep. And therein lies the problem.

If folks are doing a job that can be done by a mid-level provider, they are right to be worried, because those jobs are going to be at risk. Our national spending on healthcare is obscene, so if work can be done comparatively as well for much cheaper...

But if folks are doing work that mid-levels can't do comparatively, I wouldn't worry so much.

I don't see NPs taking away jobs from psychiatrists doing Consult, integrated care clinic, leading SMI care teams, comprehensive addiction treatment, inpatient psych, psychodynamic psychotherapy, etc etc.




Sent from my iPhone using Tapatalk

 

[bd290]

I don't see NPs taking away jobs from psychiatrists doing Consult, integrated care clinic, leading SMI care teams, comprehensive addiction treatment, inpatient psych, psychodynamic psychotherapy, etc etc.

Oh so just the majority of psychiatrists should be worried, what a relief.

 

[notdeadyet]

Oh so just the majority of psychiatrists should be worried, what a relief.

You reckon? If a majority of psychiatrists' work consists of upping Zoloft a notch and doing 15 minutes of supportive therapy, we are in trouble...

 

[Trousseau]

You reckon? If a majority of psychiatrists' work consists of upping Zoloft a notch and doing 15 minutes of supportive therapy, we are in trouble...

That's what psychiatrists do in the real world? That's not what I saw on my rotation at all...

 

[jl lin]

I knew a CRNA who once said that he was in every way equal to a MD and demanded the same respect.

He had to be talking smack or being sardonic. If not, being delusional in underrated by some.

 

[bd290]

You reckon? If a majority of psychiatrists' work consists of upping Zoloft a notch and doing 15 minutes of supportive therapy, we are in trouble...

Not saying that, but all the things you listed are a small proportion of psychiatrists. Most psychiatrists are definitely not inpatient/consult and the majority trend definitely doesn't seem to be in the direction of therapy.

 

[notdeadyet]

Not saying that, but all the things you listed are a small proportion of psychiatrists.

The list was not meant to be seen as exhaustive.

There are many, many ways in which a decent psychiatrist can separate themselves from mid-levels. Folks who don't want to do that and would rather try to focus on services that someone can do an adequate job supplying for 1/2 the price is going to have a rough road. This isn't a psych thing and it isn't a medicine thing, it's just economics.

 

[sunlioness]

I think I a well trained mid level with supervision and appropriate back-up could do a lot of what I'm doing now. I would actually like to move in the direction of working at an integrated care clinic.

It's hard you know . . . I'm at community mental health right now. And when people are stable, I think a PA or NP could totally check in with them for a brief follow up and med refill. When they come in psychotic or manic, perhaps not so much. But if I were doing community mental health and ONLY doing 15 minute med checks on decompensated folks in some sort of crisis? Holy crap. No. No, thank you. The straightforward stable follow ups keep you sane.


Sent from my iPhone using Tapatalk

 

[smalltownpsych]

I think I a well trained mid level with supervision and appropriate back-up could do a lot of what I'm doing now. I would actually like to move in the direction of working at an integrated care clinic.

It's hard you know . . . I'm at community mental health right now. And when people are stable, I think a PA or NP could totally check in with them for a brief follow up and med refill. When they come in psychotic or manic, perhaps not so much. But if I were doing community mental health and ONLY doing 15 minute med checks on decompensated folks in some sort of crisis? Holy crap. No. No, thank you. The straightforward stable follow ups keep you sane.


Sent from my iPhone using Tapatalk

Completely agree with this sentiment and only wish that was the direction the field was going.

 

[notdeadyet]

that said the reality is there just aren't enough psychiatrists even in major metropolitan areas to provide mental healthcare. even in NYC people were actual psychiatric illnesses as opposed to the worried well struggle to find psychiatric help.

Absolutely.

If folks are interested, there's a great tool put out by the AMA that lets you see where Psychiatrists actually practice. You can drill down to a county by county view, seeing how many Psychiatrists practice in an area and the shrink-to-population ration. They presented this at an advocacy event i went to recently:
http://www.ama-assn.org/ama/pub/advocacy/state-advocacy-arc/health-workforce-mapper.page

I fantasize sometimes about moving to a nearby beautiful rural area and working for the county plus setting up shop in an area that has a ration of 1 psychiatrist per 10K people. I currently live in a major metropolitan area in which there are about 1600 people per psychiatrist. And guess what? Patients with insurance wait several months to get a slot with a psychiatrist. And not necessarily a good one.

and NPs are not exactly clamoring to work in mental health. I really don't see them as some sort of "threat". and the sad reality is the majority of psychiatrists are just so awful it is hard to make the case that other kinds of mental health professionals should not have a similar scope of practice given that the standard of care in our field is so low

Yep, this is very much the case. Medicine is moving more and more to a team-based approach, and part of that is going to be shifting some of what MDs do to mid-levels. Psychiatrists need to focus on what we can provide that others can't rather than doubling down on trying to hold on to work that others can take over. Sorry, but that ship sailed. We do not have the resources to meet the demand, and I shudder at the idea of just increasing residency slots because quite frankly the quality control is already not what it should be: our field has more people who have no business practicing in it than I notice in other fields.

<editorializing> And it may just be me, but I often notice that people in the medical community that argue loudest and strongest against mid-levels taking away work from us are often the same ones that fought loudest and strongest against pushes for single-payer healthcare systems that would have potentially reduced the huge healthcare budget burden that goes to the administrative and insurance pockets. By keeping our current insurance system intact, we've increased the need to cut costs elsewhere and we've chosen cutting back on healthcare delivery more than overhead. Well done.</editorializing>

 

[Rogue Penguin]

Absolutely.
And it may just be me, but I often notice that people in the medical community that argue loudest and strongest against mid-levels taking away work from us are often the same ones that fought loudest and strongest against pushes for single-payer healthcare systems that would have potentially reduced the huge healthcare budget burden that goes to the administrative and insurance pockets. By keeping our current insurance system intact, we've increased the need to cut costs elsewhere and we've chosen cutting back on healthcare delivery more than overhead. Well done.</editorializing>

Right? It's almost like people are trying to help the big corporations rather than themselves. The insurance system that puts this strain on us while making a profit for itself it what we should be fighting in my opinion.

 

[Doctor Bagel]

ah but NPs often work in integrated care/collaborative care programs, and at some hospitals NPs are doing the psych consults....

and in one state at least they now have parity for billing so can bill as much as psychiatrists and thus aren't any cheaper...

that said the reality is there just aren't enough psychiatrists even in major metropolitan areas to provide mental healthcare. even in NYC people were actual psychiatric illnesses as opposed to the worried well struggle to find psychiatric help. and NPs are not exactly clamoring to work in mental health. I really don't see them as some sort of "threat". and the sad reality is the majority of psychiatrists are just so awful it is hard to make the case that other kinds of mental health professionals should not have a similar scope of practice given that the standard of care in our field is so low

In my community mental health job, there is no distinction at all in work functioning between NPs and MD/DOs. Same is true with the other community mental health place where I did moonlighting. Everyone is an LMP or "prescriber." MD/DOs do make more money -- I'm not sure how much more but definitely more, and again, I've heard that someone they can bill for more even though I am in that parity state. You're right, though, that it's not always clear that physicians are the better providers than mid-levels.

I've got to say, though, I've been really disappointed in our leadership because I don't think anyone has come up with a clear articulation of what our role should be while acknowledging that NPs are here and being respectful of what they could contribute -- when we move away from being respectful, we sound like arrogant and greedy jerks, playing into everyone's stereotype about doctors.

 

[bd290]

I fantasize sometimes about moving to a nearby beautiful rural area and working for the county

This is my personal idea of hell. But, more power to you

 

[rkaz]

Heh. I'm tired of guys on dates asking, "are you analyzing me right now?" And then following it up with the joke, "let me save you the trouble. I already know I'm crazy"

So maybe get married before you have to tell people that's what you do. Heh.

I usually say, "no, I'm not an analyst". But no one gets it. Maybe that's why I'm still single.

Hilarious. I get a lot of the same.... men who will tell me on the first phone conversation/first date about their bipolar disorder or past suicide attempts, or asking if I am analyzing them when I am making eye contact. Although I definitely don't want to stigmatize anyone for their MH history, it makes me see them more as a patient rather than a potential romantic interest. Not that I wouldn't be open to a high-functioning partner with a low-level of MH history, but at least wait until you know someone well enough before such disclosures.

 

[WingedOx]

<editorializing> And it may just be me, but I often notice that people in the medical community that argue loudest and strongest against mid-levels taking away work from us are often the same ones that fought loudest and strongest against pushes for single-payer healthcare systems that would have potentially reduced the huge healthcare budget burden that goes to the administrative and insurance pockets. By keeping our current insurance system intact, we've increased the need to cut costs elsewhere and we've chosen cutting back on healthcare delivery more than overhead. Well done.</editorializing>

the various boards on SDN are proof positive of that. The problem is that the people arguing this issue the loudest are the ones arguing it the most poorly. There's so much attacking of strawmen that the important arguments get lost in the shouting.

 

[PsyDr]

I always thought that if I were a psychiatrist, I would use the supervision requirements of LA and NM + low salary requirements + lack of education in EM coding for rxp psychologists, and create a cheap workforce. There's probably a reason that no one is doing this, but I dunno.

 

[notdeadyet]

the various boards on SDN are proof positive of that. The problem is that the people arguing this issue the loudest are the ones arguing it the most poorly. There's so much attacking of strawmen that the important arguments get lost in the shouting.

Boy that's modern day politics in a nutshell isn't it? Sigh...

 

[DD214_DOC]

The more NPs I work with, the less respect I have for the field as an autonomous and independent provider of care. It's actually scary how much autonomy they are getting given their skills and experience.

 

[Doctor Bagel]

The more NPs I work with, the less respect I have for the field as an autonomous and independent provider of care. It's actually scary how much autonomy they are getting given their skills and experience.

Quality seems really variable, which is kind of like with us. As their training is less regimented than ours, I suspect that leads to even more variation (online schools versus brick and mortar places, people who sought out solid mentorship after leaving training versus those who didn't, etc.). There are little things that seem surprising to me, too, like for example we had a patient who had a positive ANA -- the nurse practitioners didn't seem to know what an ANA was, which just seems like basic medicine 101 type of stuff to us.

It's a hard thing to navigate, though, because you don't want to be an elitist jerk, but we really do get more training. And selfishly, I have a lot more debt, so I kinda need to make more money. I get that the public doesn't care about that and all, but it's still a pretty significant concern for me and I imagine for lots of us.

 

[Psychotic]

I always thought that if I were a psychiatrist, I would use the supervision requirements of LA and NM + low salary requirements + lack of education in EM coding for rxp psychologists, and create a cheap workforce. There's probably a reason that no one is doing this, but I dunno.

Please elaborate on the supervision reqs of LA and NM - not sure I know what those are?

 

[smalltownpsych]

psychologists cannot use E&M codes, even in those states.

So how does a psychologist with prescriptive authority in one of those states get paid? If they are just billing for psychotherapy codes like 90834, then why take on the added work and liability of prescribing? That doesn't make much sense.

 

[smalltownpsych]

E&M codes are medical codes so psychologists cant use them. There is a specific CPT code for psychologist prescribing

Ah, I see it is an add-on code 90863. Interesting that a psychologist in one of those states would bill medication management as an add-on to psychotherapy, whereas a psychiatrist would bill psychotherapy as an add-on to medical management.

 

[DD214_DOC]

Quality seems really variable, which is kind of like with us. As their training is less regimented than ours, I suspect that leads to even more variation (online schools versus brick and mortar places, people who sought out solid mentorship after leaving training versus those who didn't, etc.). There are little things that seem surprising to me, too, like for example we had a patient who had a positive ANA -- the nurse practitioners didn't seem to know what an ANA was, which just seems like basic medicine 101 type of stuff to us.

It's a hard thing to navigate, though, because you don't want to be an elitist jerk, but we really do get more training. And selfishly, I have a lot more debt, so I kinda need to make more money. I get that the public doesn't care about that and all, but it's still a pretty significant concern for me and I imagine for lots of us.

Yeah, I agree with this. There are plenty of terrible physicians out there, and merely being one doesn't mean you're good at what you do. Having said that, however, there are just really basic things that the numerous NP's I have encountered just simply didn't know. Things that a medical student probably would have known, or at least should have known. Their greatest accomplishment is in fooling the public that they are something they're not, and making it anathema to question the quality or rigor of their training. They've created a pretend land where a huge disparity in both educational hours and experience aren't relevant, when reality is that more time spent in training and education usually leads to higher levels of skill. Despite the fantasy land a lot of people seem to enjoy living in, we are not all equal.

Sure, medicine looks easy when you just follow basic algorithms and function as a referral machine. But when something presents that falls outside of that paradigm, then what?

 

[clausewitz2]

Yeah, I agree with this. There are plenty of terrible physicians out there, and merely being one doesn't mean you're good at what you do. Having said that, however, there are just really basic things that the numerous NP's I have encountered just simply didn't know. Things that a medical student probably would have known, or at least should have known. Their greatest accomplishment is in fooling the public that they are something they're not, and making it anathema to question the quality or rigor of their training. They've created a pretend land where a huge disparity in both educational hours and experience aren't relevant, when reality is that more time spent in training and education usually leads to higher levels of skill. Despite the fantasy land a lot of people seem to enjoy living in, we are not all equal.

Sure, medicine looks easy when you just follow basic algorithms and function as a referral machine. But when something presents that falls outside of that paradigm, then what?

Honestly though in places where it takes six weeks to see a private psychiatrist sometimes a more accessible first-line algorithm and referral machine would do worlds of good, especially in helping acute-ish presentations avoid hospitalization.

 

[W19]

Quality seems really variable, which is kind of like with us. As their training is less regimented than ours, I suspect that leads to even more variation (online schools versus brick and mortar places, people who sought out solid mentorship after leaving training versus those who didn't, etc.). There are little things that seem surprising to me, too, like for example we had a patient who had a positive ANA -- the nurse practitioners didn't seem to know what an ANA was, which just seems like basic medicine 101 type of stuff to us.

It's a hard thing to navigate, though, because you don't want to be an elitist jerk, but we really do get more training. And selfishly, I have a lot more debt, so I kinda need to make more money. I get that the public doesn't care about that and all, but it's still a pretty significant concern for me and I imagine for lots of us.

What?

 

[DD214_DOC]

Honestly though in places where it takes six weeks to see a private psychiatrist sometimes a more accessible first-line algorithm and referral machine would do worlds of good, especially in helping acute-ish presentations avoid hospitalization.

Yes, they have their role, I get it. But to be fully independent? No way. I'm not confident in their ability to both recognize and admit when they are in over their heads.

 

[Doctor Bagel]

Honestly though in places where it takes six weeks to see a private psychiatrist sometimes a more accessible first-line algorithm and referral machine would do worlds of good, especially in helping acute-ish presentations avoid hospitalization.

Yeah, totally, and I don't think anyone is arguing that NPs don't have a place in medicine. Honestly, I think in some ways we need to be more inclusive and open to NPs, while helping to shape some idea of what the different roles between NPs and psychiatrists are. If things keep going where they are going, I suspect we're going to wind up in a world where the roles are identical, at least in employed settings.

 

[DD214_DOC]

Yeah, totally, and I don't think anyone is arguing that NPs don't have a place in medicine. Honestly, I think in some ways we need to be more inclusive and open to NPs, while helping to shape some idea of what the different roles between NPs and psychiatrists are. If things keep going where they are going, I suspect we're going to wind up in a world where the roles are identical, at least in employed settings.

I have offered to work with FNPs to increase their knowledge and skill for common psych stuff they'd encounter in that setting. Their level of resistance is astonishing. I get tons of inappropriate referrals from NPs who claim to be, "uncomfortable" with even basic psych meds, or who will even lie to patients and fall back on, "I can't prescribe that because I'm just a NP" to avoid addressing psych issues.