What! Another pt on klonopin AND adderall!

[cherryalmond]

Is this a new trend--patients being on klonopin and adderall? In the past month I have seen two new patients who report to me they are on both klonopin and adderall as well as other meds but why two controlled substancese at the same time! Now both of these patients were in 8 week partial hospitalization programs which is where the adderall was started. So now they expect me to continue it for them. I find this annoying and even when I tell them I am not prescribing them adderall they continue to ask for it repeatedly.

It's clear I am not comfortable prescribing both but I am wondering from more experienced psychiatrists if there would ever be a valid reason/dx for a patient to be on both a benzo and a stimulant. I guess if a patient has ADD and panic attacks but I am not comfortable with this as a stimulant can cause anxiety and klonopin can cause poor focus. Please someone give me a good reason to keep a patient on both of these.

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[notdeadyet]

Methylphenidate is used for other conditions than ADHD. It's used with melancholic depression refractory to other meds, for one...

 

[vistaril]

Is this a new trend--patients being on klonopin and adderall? In the past month I have seen two new patients who report to me they are on both klonopin and adderall as well as other meds but why two controlled substancese at the same time! Now both of these patients were in 8 week partial hospitalization programs which is where the adderall was started. So now they expect me to continue it for them. I find this annoying and even when I tell them I am not prescribing them adderall they continue to ask for it repeatedly.

It's clear I am not comfortable prescribing both but I am wondering from more experienced psychiatrists if there would ever be a valid reason/dx for a patient to be on both a benzo and a stimulant. I guess if a patient has ADD and panic attacks but I am not comfortable with this as a stimulant can cause anxiety and klonopin can cause poor focus. Please someone give me a good reason to keep a patient on both of these.

new trend? Are you being serious? What settings have you worked in in the past? In a lot of private practice outpt clinics a benzo + a stimulant isn't that uncommon......sad, but true.

And perhaps there is a valid reason somewhere in some patient for some period of time why this would be indicated......but let's be real that isn't the case here. And despite the fact that most of us do have a good number of pts on scheduled benzos for more than a few weeks, there is no evidence that this is good for pts or their anxiety at all. Even for panic d/o(prn of course is different)


My question- what capacity are you seeing them in, what is their payor source, and who pays your salary? If you work for a cmhc, the va, an agency that deals with medicaid pts, or any other salaried position you should of course tell these patients no and just leave it at that. I wouldn't 'bargain' with them at all. No means no. That's the best part of salaried outpt jobs where there is no pressure from employer to 'keep' patients. Now if you are salaried for some place else and there is some pressure to keep patients, that sorta sucks and puts you in somewhat of a bind.

Now if you are in outpt private practice and they have insurance(or are self pay) and you don't continue to fill these meds, they will just go somewhere else and get what they want....and believe me they will get it. So you will lose patients and watch other outpt pp rake in $. The flip side is to keep them as patients, practice bad psychiatry, and somehow try to justify it to yourself(ie at least your limiting the dose, monitoring that he doesnt doctor shop, etc).....but you're still going to likely feel sleazy the next day.

 

[vistaril]

Methylphenidate is used for other conditions than ADHD. It's used with melancholic depression refractory to other meds, for one...

she has completed residency....Im sure she knows that. The problem is that the benzo is illogical in that case. If someone's depression is to the point they just lay around with anhedonia, no energy to get out of bed, sleep a lot of the day, gloomy face all day, etc....you're not going to have that pt on 2 or 3 mg of Klonopin a day. That would be illogical.

The only real justification(and I say this as someone who has inherited pts on stims and benzos and kept both going for some time for various reasons) is if you have an adult with 'real' adhd(I mean it's just obvious) who also maybe has severe anxietty associated with an acute stress d/o type picture and you are temporarily treating them a benzo until things settle down just a bit over time....and even then, depending on the circumstances, one might address the stimulant(temporarily) while the pt goes through this.

 

[splik]

this would be a good combo for a patient with REM sleep behavior disorder and narcolepsy.

It may be an acceptable treatment for a patient with refractory melancholic depression with malignant catatonia.

It would also be the gold standard for a patient with comorbid amphetamine and bezodiazepine deficiency disorders

 

[vistaril]

this would be a good combo for a patient with REM sleep behavior disorder and narcolepsy.

It may be an acceptable treatment for a patient with refractory melancholic depression with malignant catatonia.
)

the first patient the psychiatrist likely isn't going to be the primary provider....likely. Unless they are one of the rare psych sleep persons....and really in that case they are practicing sleep medicine and not psychiatry.

the second patient....ummm.....pretty sure they aren't going to be managed in cherryalmonds outpt clinic.

 

[hamstergang]

Now if you are salaried for some place else and there is some pressure to keep patients, that sorta sucks and puts you in somewhat of a bind.

Ugh, does this really happen? I would never prescribe something that I didn't think was in the patient's best interest just to keep them happy and coming back so my employer would be happy.

 

[BobA]

Is this a new trend--patients being on klonopin and adderall? In the past month I have seen two new patients who report to me they are on both klonopin and adderall as well as other meds but why two controlled substancese at the same time! Now both of these patients were in 8 week partial hospitalization programs which is where the adderall was started. So now they expect me to continue it for them. I find this annoying and even when I tell them I am not prescribing them adderall they continue to ask for it repeatedly.

It's clear I am not comfortable prescribing both but I am wondering from more experienced psychiatrists if there would ever be a valid reason/dx for a patient to be on both a benzo and a stimulant. I guess if a patient has ADD and panic attacks but I am not comfortable with this as a stimulant can cause anxiety and klonopin can cause poor focus. Please someone give me a good reason to keep a patient on both of these.

If we ever went to pay for performance in psychiatry, I think this might be one good metric. If you prescribe a stimulant and a benzo you get paid less for that visit.

 

[vistaril]

Ugh, does this really happen? I would never prescribe something that I didn't think was in the patient's best interest just to keep them happy and coming back so my employer would be happy.

well usually in the outpt world of private insurance(or self pay), you are your employer....so it's usually not an issue. If you don't want to play the game, you will lose money(vs someone else who is) however.

But sure....if you are salaried for an organization which has strong financial incentives to 'keep' patients, of course you are going to come under fire if you are losing tons of patients. What is it that you think they are employing you for- to make money for them ultimately.

 

[vistaril]

If we ever went to pay for performance in psychiatry, I think this might be one good metric. If you prescribe a stimulant and a benzo you get paid less for that visit.

well, who is 'paying'?

 

[BobA]

well, who is 'paying'?

I hear what you're saying. It does seem to be that many of the fancy cash only pp docs make a living prescribing benzo and stimulants, unfortunately.

I'm just talking about medicare/medicaid, and possibly private insurance

 

[vistaril]

I hear what you're saying. It does seem to be that many of the fancy cash only pp docs make a living prescribing benzo and stimulants, unfortunately.

I'm just talking about medicare/medicaid, and possibly private insurance

the medicaid and(to a large extent) medicare populations arent calling their own shots now on stims and benzos anyways. A lot of these pts are treated at cmhcs and many have no outpt benzo policies, either formally or informally. The pts have little leverage to get these drugs if they really arent indicated.

With the private insurance world, however, you have to keep in mind that it is still a service oriented business(insurance I mean). If I am a school teacher and have humana insurance, and my humana plan is penalizing the doctors who are in network for them by not giving me the drugs I want, I *am* going to be mad at humana....and I'm likely to pick another of the insurance plans that many employees get the choose from. Now that may be a simple and perhaps too convenient example, but the basic principle stands.

additionally, why would insurers want to do this apart from upsetting their customers? Benzos are really cheap and many stimulants arent that expensive(Adderall IR for example).....insurers would far prefer their patients on this than Abilify or somesuch for example.

 

[vistaril]

the medicaid and(to a large extent) medicare populations arent calling their own shots now on stims and benzos anyways. A lot of these pts are treated at cmhcs and many have no outpt benzo policies, either formally or informally. The pts have little leverage to get these drugs if they really arent indicated.

With the private insurance world, however, you have to keep in mind that it is still a service oriented business(insurance I mean). If I am a school teacher and have humana insurance, and my humana plan is penalizing the doctors who are in network for them by not giving me the drugs I want, I *am* going to be mad at humana....and I'm likely to pick another of the insurance plans that many employees get the choose from. Now that may be a simple and perhaps too convenient example, but the basic principle stands.

additionally, why would insurers want to do this apart from upsetting their customers? Benzos are really cheap and many stimulants arent that expensive(Adderall IR for example).....insurers would far prefer their patients on this than Abilify or somesuch for example.

to take this farther, what is the image so many of us have of the 'drug seeker' we see in the outpt world? It is the person at the VA constantly asking for benzos and stimulants. Or someone in the ER who keeps coming back just asking for one more refill(or even 10-15) xanax. this is somewhat skewed(and Im guilty of it to some extent as well)....there are tons of chemical copers and drug seekers in the outpt world, but these patients *get what they want* already so they don't have to resort to going to the ER and bugging their VA psych(if they are a vet) for controlled substances.....they may feel out the VA lightly, but if they encounter resistance they just say "hell with it, I've got private insurance or a little coin in my pocket, I'll just see someone outside the VA"...the people without money or private insurance thus gets exposed disproportionally(from the standpoint of most residents)

 

[hamstergang]

But sure....if you are salaried for an organization which has strong financial incentives to 'keep' patients, of course you are going to come under fire if you are losing tons of patients. What is it that you think they are employing you for- to make money for them ultimately.

Yeah, I could see them being upset, but I don't see how it puts you in a bind unless you don't care much about doing right by your patient.

 

[vistaril]

Yeah, I could see them being upset, but I don't see how it puts you in a bind unless you don't care much about doing right by your patient.

only the patients without resources are in a bind. And I use that phrase to indicate that is how the pt views their predicament, not how I view ideal treatment.

Pts with resources are never without access to rx benzos and stimulants if they want them. They are mildly annoyed that they have wasted their time, but they will just go give their money(or their insurances money) to some other psychiatrist who will refill their adderall and klonopin or xanax.

 

[hamstergang]

only the patients without resources are in a bind.

You said that the psychiatrist was in a bind, not the patient. So I'm not sure what's going on here.

Now if you are salaried for some place else and there is some pressure to keep patients, that sorta sucks and puts you in somewhat of a bind.

 

[pipe dream]

Just a 3rd year here, but I saw a patient on a stimulant and a benzo last week. I asked why and it turns out the patient travels a lot for his job and has a severe fear of flying. He takes the benzo on flights, then on days he's working wherever he ends up, that's when he takes the stimulant. He doesn't take them on the same days. If he's going to fly, he skips his stimulant that day and if he doesn't fly, he doesn't need his benzo. Just one explanation about why a doctor might prescribe both.

 

[vistaril]

Just a 3rd year here, but I saw a patient on a stimulant and a benzo last week. I asked why and it turns out the patient travels a lot for his job and has a severe fear of flying. He takes the benzo on flights, then on days he's working wherever he ends up, that's when he takes the stimulant. He doesn't take them on the same days. If he's going to fly, he skips his stimulant that day and if he doesn't fly, he doesn't need his benzo. Just one explanation about why a doctor might prescribe both.[/QUOTE

I think it is pretty understood in this thread amongst practitioners that we are referring to scheduled benzo dosing....

although to be honest, a lot of practitioners justify this sort of thing(benzos + stims) to themselves by writing prn on the script and telling the pt to take it only when needed. It just so happens that the psych keeps filling it, 60 or 90 pills a month with 2 refills every 3 months......

also, the larger question(depending on how much he is flying) is why someone who has a 'severe fear of flying' took a job that requires him to fly 5 times per week.

 

[vistaril]

You said that the psychiatrist was in a bind, not the patient. So I'm not sure what's going on here.

ok now I looked back and see the specific quote in question. And yes, that does put the psychiatrist in a bind. (specifically in the practice example I cite- working as a salaried outpt doc to private paying or insured patients for an organization that wants you to 'keep' these patients).....

If you don't think the patient needs or should have these drugs, they will give their $ to someone else and your employers will not be happy as you are costing them money and you may end up looking for another job.

If you do give the patient what you think he doesn't need or shouldnt have, you've sacrificed your own principles of care to keep your employer happy.


So yeah, that's a classic bind. Now the person can always go work for a cmhc or whatever, but those tend to pay a little less.

 

[cherryalmond]

I should've been more specific. There have been some patients I inherited at the clinic I work at, which by the way doesn't accept medicaid, who are on both a benzo and a stimulant but they take the benzo infrequently for panic. I for one think that stimulants like adderall, concerta are being overprescribed cause everyone seems to endorse ADD symptoms. The thing is even if you don't have ADD you will get benefit in focus;etc by taking a stimulant so now everyone wants to improve their performance and get that extra edge.
The clinic is quota driven but I do not feel pressure to prescribe medications that patients want such as stimulants or benzos. I won't prescribe what I am not comfortable prescribing.
Thanks for all the responses.

 

[vistaril]

I should've been more specific. There have been some patients I inherited at the clinic I work at, which by the way doesn't accept medicaid, who are on both a benzo and a stimulant but they take the benzo infrequently for panic. I for one think that stimulants like adderall, concerta are being overprescribed cause everyone seems to endorse ADD symptoms. The thing is even if you don't have ADD you will get benefit in focus;etc by taking a stimulant so now everyone wants to improve their performance and get that extra edge.
The clinic is quota driven but I do not feel pressure to prescribe medications that patients want such as stimulants or benzos. I won't prescribe what I am not comfortable prescribing.
Thanks for all the responses.

so how do you meet your 'quota' if you don't prescribe these patients the stimulant(I sense you are thinking the adhd dx is bs) and they go somewhere else(which they can if they arent medicaid pts)?

 

[Armadillos]

I should've been more specific. There have been some patients I inherited at the clinic I work at, which by the way doesn't accept medicaid, who are on both a benzo and a stimulant but they take the benzo infrequently for panic. I for one think that stimulants like adderall, concerta are being overprescribed cause everyone seems to endorse ADD symptoms. The thing is even if you don't have ADD you will get benefit in focus;etc by taking a stimulant so now everyone wants to improve their performance and get that extra edge.
The clinic is quota driven but I do not feel pressure to prescribe medications that patients want such as stimulants or benzos. I won't prescribe what I am not comfortable prescribing.
Thanks for all the responses.

Its really that easy, not sure why some posters seem to think otherwise.

 

[michaelrack]

x

 

[PikminOC]

I hear what you're saying. It does seem to be that many of the fancy cash only pp docs make a living prescribing benzo and stimulants, unfortunately.

I'm just talking about medicare/medicaid, and possibly private insurance

I'm not making a huge living..and Im not fancy.
But I dont prescribe these things.
These patients can get their insurance to cover the docs that will.

 

[vistaril]

I'm not making a huge living..and Im not fancy.
But I dont prescribe these things.
These patients can get their insurance to cover the docs that will.

so what sort of net profit are you generating?

 

[vistaril]

Its really that easy, not sure why some posters seem to think otherwise.

of course it is, and it is right to take that stance....Im just pointing out the fact that in some settings it is costly to take that stance for the psychiatrist from a $/business/employment standpoint.

 

[notdeadyet]

of course it is, and it is right to take that stance....Im just pointing out the fact that in some settings it is costly to take that stance for the psychiatrist from a $/business/employment standpoint.

Sure. And if you get static from your superiors for doing the only right thing clinically, you change jobs. It's also costly to not run a marijuana clinic or pill mill, but we somehow are able to make that sacrifice.

 

[vistaril]

Sure. And if you get static from your superiors for doing the only right thing clinically, you change jobs. It's also costly to not run a marijuana clinic or pill mill, but we somehow are able to make that sacrifice.

well it's all all along a spectrum........running a 'pill mill'(highly illegal) and being the outpt pp psychiatrist who has pts on stimulants for questionable adult adhd are at two very different points in a spectrum.

No mainstream jobs are going to expect you to do the former. The latter is a different ballgame alltogether.

 

[Therapist4Chnge]

There are instances when both a psychostimulant and a benzo can be use concurrent....and with good reasoning. However, I'm sure the vast majority of the people out there don't actually need them. Legit ADHD (w. testing, documented childhood history, etc) makes sense for the psychostimulant. Same with Narc, tx resistant dep/post-chemo cog+mood issues/elderly w. initiation issues...with the last 3 being far less frequent. Take one of the above and add a pre-existing hx. of anxiety dx (w. failed multiple trials on non-benzos), infrequent use for public speaking (if failed beat-blocker trial), maybe xanax for a fear of flying/going to the dentist, etc. So there are instances...but I'm guessing the vast majority of patients coming through the clinic haven't actually given a legit go of a non-stimulant & non-benzo use. I'm sure even less have tried *gasp* talk therapy/anxiety management/learning coping strategies prior to or in conjunction with a pharma option.

If you are writing the 'script....it is your decision, your license, and your responsibility. Patients may go elsewhere, but that isn't really your problem. As my parents said about 1000x to me when I was a kid, "I don't care what [insert person's name] does, *you* aren't them." Stick to your guns because over-prescribing, particularly of these two types of meds are far more likely to get you reviewed/audited than underprescribing. If you do prescribe a psychostimulant for something like ADHD....get a neuropsych*, get school records, etc.

*Admittedly I have a bias about this...but a proper neuropsych assessment has far better support than accepting a patient's word when there are clear secondary gains at play in the vast majority of cases or using some self-report checklists that is easy to manipulate.

 

[Scorcher31]

Much of what we know today is very different than when our attendings were just in residency. The longer I spend in psych the more i realize how little anyone really knows... myself included. Things we think we know will significantly change over the next 20 years.

Sometimes I have the philosphoy don't rock the boat. If you have a patient that was an absolute mess with multiple hospitalizations in the past, wasn't able to function, dangerous, etc and they have been doing great the past 5 or 10 years on a weird regimen like that with no problems (loosing meds, asking for them early, asking to consistently elevate dose) why not leave well enough alone.

 

[Scorcher31]

There are instances when both a psychostimulant and a benzo can be use concurrent....and with good reasoning. However, I'm sure the vast majority of the people out there don't actually need them. Legit ADHD (w. testing, documented childhood history, etc) makes sense for the psychostimulant. Same with Narc, tx resistant dep/post-chemo cog+mood issues/elderly w. initiation issues...with the last 3 being far less frequent. Take one of the above and add a pre-existing hx. of anxiety dx (w. failed multiple trials on non-benzos), infrequent use for public speaking (if failed beat-blocker trial), maybe xanax for a fear of flying/going to the dentist, etc. So there are instances...but I'm guessing the vast majority of patients coming through the clinic haven't actually given a legit go of a non-stimulant & non-benzo use. I'm sure even less have tried *gasp* talk therapy/anxiety management/learning coping strategies prior to or in conjunction with a pharma option.

If you are writing the 'script....it is your decision, your license, and your responsibility. Patients may go elsewhere, but that isn't really your problem. As my parents said about 1000x to me when I was a kid, "I don't care what [insert person's name] does, *you* aren't them." Stick to your guns because over-prescribing, particularly of these two types of meds are far more likely to get you reviewed/audited than underprescribing. If you do prescribe a psychostimulant for something like ADHD....get a neuropsych*, get school records, etc.

*Admittedly I have a bias about this...but a proper neuropsych assessment has far better support than accepting a patient's word when there are clear secondary gains at play in the vast majority of cases or using some self-report checklists that is easy to manipulate.

Stimulants have also been shown to be helpful in certain cognitive deficets post TBI. Again though it's something you can give a shot. if it significantly helps, then great; if it dosen't really help, just stop it. Don't leave it sitting there if it isin't doing anything.

 

[Therapist4Chnge]

Stimulants have also been shown to be helpful in certain cognitive deficets post TBI. Again though it's something you can give a shot if it significantly helps great if it dosen't really help just stop it. Don't leave it sitting there if it isin't doing anything.

Good point. I actually work quite a bit with this population, I just left them out for simplicity's sake. I have seen some excellent results in the acute in-patient rehab setting for post-TBI and low dose methylphenidate, increasing both initiation and cognition. It is often a night and day difference. Older > Younger population, but that could also do with sensitivity, as 2.5mg-5mg can be effective in the former.

 

[vistaril]

Sometimes I have the philosphoy don't rock the boat. If you have a patient that was an absolute mess with multiple hospitalizations in the past, wasn't able to function, dangerous, etc and they have been doing great the past 5 or 10 years on a weird regimen like that with no problems (loosing meds, asking for them early, asking to consistently elevate dose) why not leave well enough alone.

well sure...and I think we all do that sometimes when we inherit such a patientt. But the downside is it doesn't take a lot of skill, intellect,etc.....I mean my 12 year old cousin(and he isn't even an A/B student in 7th grade) could do an intake on such patients and say "ok, since things are going ok and you like your current meds the way they are, we will just hold steady for now"......

 

[PikminOC]

well sure...and I think we all do that sometimes when we inherit such a patientt. But the downside is it doesn't take a lot of skill, intellect,etc.....I mean my 12 year old cousin(and he isn't even an A/B student in 7th grade) could do an intake on such patients and say "ok, since things are going ok and you like your current meds the way they are, we will just hold steady for now"......

Then you should hire your cousin to work for you. Why pay for a noctor?

 

[benlinus]

Then you should hire your cousin to work for you. Why pay for a noctor?

What's a noctor?

 

[michaelrack]

What's a noctor?

derogatory term for a nurse practitioner (especially one who is a DNP)

 

[jettavr6]

Just when I thought I had seen it all, I saw a patient today who is being treated with 3 different benzodiazepines at the same time. Klonopin, Ativan, and Xanax all being prescribed at the same time by a board certified psychiatrist.

 

[vistaril]

Just when I thought I had seen it all, I saw a patient today who is being treated with 3 different benzodiazepines at the same time. Klonopin, Ativan, and Xanax all being prescribed at the same time by a board certified psychiatrist.

the saddest part of what you write above....i'm not all that surprised.

 

[PikminOC]

At least if the doc gets sued for this, he will take the fall, as well as his license.
Can the same be said for a noctor?

And noctor is a derogatory term for them, as these nurses want to be called DOCTOR.
DNP.

 

[vistaril]

Then you should hire your cousin to work for you. Why pay for a noctor?

that's a reality that in many settings(such as with what the VA is doing) will be more and more true in the coming years.

every psychiatrist(well really every physician in many but not all specialties) should ask themselves the following question: what I am doing on a day to day basis to set myself apart from psych np's? And no, saying "I went to medical school and passed steps 1,2,3, and 24" is not *doing* anything.....

 

[F0nzie]

Just when I thought I had seen it all, I saw a patient today who is being treated with 3 different benzodiazepines at the same time. Klonopin, Ativan, and Xanax all being prescribed at the same time by a board certified psychiatrist.

That patient got the party pack.

 

[Scorcher31]

well sure...and I think we all do that sometimes when we inherit such a patientt. But the downside is it doesn't take a lot of skill, intellect,etc.....I mean my 12 year old cousin(and he isn't even an A/B student in 7th grade) could do an intake on such patients and say "ok, since things are going ok and you like your current meds the way they are, we will just hold steady for now"......

Im not arguing that, but do you truly believe dsm is much more than a hodge podge of symptoms. Most of these conditions are extremely heterogeneous. My point being sometimes we don't know what we think we know and it it's better tolook to how the paient is actually doing/functioning and not so much if the dx and tx oficially line up for legal purposes. Heck abilify isin't approved for bipolar depression, but if it helps it helps. Sure it's understated in comparison to klonopin and adderall, but I would argue for all the physicians who overprescribe, there are many physicians that under prescribe because they are too scared of these meds.

 

[vistaril]

Im not arguing that, but do you truly believe dsm is much more than a hodge podge of symptoms. Most of these conditions are extremely heterogeneous. My point being sometimes we don't know what we think we know and it it's better tolook to how the paient is actually doing/functioning and not so much if the dx and tx oficially line up for legal purposes. Heck abilify isin't approved for bipolar depression, but if it helps it helps. Sure it's understated in comparison to klonopin and adderall, but I would argue for all the physicians who overprescribe, there are many physicians that under prescribe because they are too scared of these meds.

completely agree with the first part of your post. The second part....couldnt disagree more. Dont know a single psychiatrist who underprescribes 'because they are too scared of these meds'....would be nice if that were actually the case though. Maybe we would have more sensible community practice.

 

[PikminOC]

completely agree with the first part of your post. The second part....couldnt disagree more. Dont know a single psychiatrist who underprescribes 'because they are too scared of these meds'....would be nice if that were actually the case though. Maybe we would have more sensible community practice.

He did not say psychiatrist, he said physician.
And in general there are OCD psychiatrists who are very careful with medications.

 

[jettavr6]

every psychiatrist(well really every physician in many but not all specialties) should ask themselves the following question: what I am doing on a day to day basis to set myself apart from psych np's? And no, saying "I went to medical school and passed steps 1,2,3, and 24" is not *doing* anything.....

Every physician in every specialty needs to ask themselves the question you posed. Some fields are more immune than others, but the day will come when NP's or PA's are going to do surgeries, albeit routine minor ones. As technology advances making surgical procedures less invasive, we'll see PA's and NP's doing more. This will be framed as an "access to care" issue, by the very powerful nursing lobbies.

Psychiatry: at the moment, at least out in the private world, the word of a board certified psychiatrist carries much more weight than a Noctor. There are a lot of ambiguities in our line of work, and people understand this. When dealing with mental health, because of many legal ramifications, it "feels" like we as psychiatrists are insulated. For example, when it comes to forensics or workers comp, the mid-levels can't substitute. Where I see (and have already seen) mid levels come into play, is after a patient has been stabilized. Renewing meds, making minor adjustments, etc.

As psychiatrists, we must be vociferous in emphasizing our medical degrees, passing our Steps 1, 2, 3, 4, 5 board examinations, etc. We should become comfortable with basic medical management --- NP's and PA's usually are. If we don't offer up what we've learned in medical school then we will start working for Psych NP's. Unfortunately, at the first sign of anything medically related, most psychiatrists reflexively send the patient out to the family practitioner, where the patient then gets seen by an NP. Basic hypothyroid, cholesterol, cold/cough? We can handle it - why the hell not?

From my experience, when it comes to mental health (at least for the moment), the public will always trust an MD or DO. The one threat that I do see is that many primary care physicians are more likely these days to hold on to and treat many of our patients. We get the patient after everything else has failed.

 

[someguy321]

of course you should give benzos with amphetamines... how else is somebody supposed to get some sleep when they're all spun out?

 

[Therapist4Chnge]

The one threat that I do see is that many primary care physicians are more likely these days to hold on to and treat many of our patients. We get the patient after everything else has failed.

Just wait until ACOs are everywhere....PCPs will handle all but the worst cases bc they'll want to hold on to the kickback $'s.

 

[JGimpel]

Probably prescribed that way because it's still better than cocaine and ketamine. Suboxone/methadone is along the same idea.

 

[PikminOC]

http://www.maine.gov/tools/whatsnew/index.php?topic=Portal+News&id=505255&v=article-2011

"Dr. Quianzon indicated that the discharge summary was prepared by a physician assistant who made a dictation error by including an incorrect medication and excessive dosage. Dr. Quianzon indicated that neither he, the physician assistant, nor the discharge nurse caught the mistake. Dr. Quianzon admitted he did not perform a medication reconciliation when he reviewed and signed the summary.

All Board disciplinary actions are reported to the National Practitioner Data Bank, the Health Integrity and Protection Data Bank, and the Federation of State Medical Boards Action Data Bank. These reports are regularly reviewed by every state licensing board in the country."

The MD was reported to the NPDB due to an error by the person he was supervising.
So does anyone else have a NPDB, the nurses? The PA's?
Because it is a BIG deal to have your name in here.

 

[vistaril]

http://www.maine.gov/tools/whatsnew/index.php?topic=Portal+News&id=505255&v=article-2011

"Dr. Quianzon indicated that the discharge summary was prepared by a physician assistant who made a dictation error by including an incorrect medication and excessive dosage. Dr. Quianzon indicated that neither he, the physician assistant, nor the discharge nurse caught the mistake. Dr. Quianzon admitted he did not perform a medication reconciliation when he reviewed and signed the summary.

All Board disciplinary actions are reported to the National Practitioner Data Bank, the Health Integrity and Protection Data Bank, and the Federation of State Medical Boards Action Data Bank. These reports are regularly reviewed by every state licensing board in the country."

The MD was reported to the NPDB due to an error by the person he was supervising.
So does anyone else have a NPDB, the nurses? The PA's?
Because it is a BIG deal to have your name in here.

\

just from that story, we have no idea what happened......we know there was a death of some sort, and we know that the physician didn't check the doses on the med rec.

That is all we know. The other relevant part of it...the other 98.8%...we don't know.