What is the future of psychiatry?

[psychma]

My husband works for a large hospital system. There is one inpatient psychiatrist and there are two outpatient psychiatrists. There are at least 10 psych nurse practitioners. A look in our greater metro area came up with a few hits for physicians, but mostly nurse practitioners. Training for psych NP’s at our institution involves having students observe sessions.

My mom is an np, and my husband (a physician) tells me she is dangerous because she doesn’t know what she doesn’t know.

Is this where psychiatry is headed? I see posts suggesting there will always be jobs for psychiatrists, but the evidence around me suggests psych NP’s are taking over.

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[TexasPhysician]

If I knew the future, I’d be a billionaire already.

There are plenty of psychiatry jobs out there. Psych NP’s are most functional with a supervising psychiatrist that is present and active.

I have yet to meet a psych NP that has a supervisor in signature only that is any good. I frequently get transfers from psych NP’s that poorly manage patients.

I recently asked a psych NP about depakote, and they admitted to not knowing why they used it at all, ever. Just prescribing to prescribe something.

 

[hippopotamusoath]

The sunnier vision of the future is that we will settle into a system where big packs of NPs have high-quality supervision and education from physicians, delivering good-quality care to many more patients. Like with CRNAs--there always seemed to be a lot of "sky is falling" rhetoric, but I work at a community hospital where the anesthesia docs supervise 4 CRNAs or something, and it seems to work well. They make a lot of money, they see a lot of patients, the outcomes seem perfectly fine. Could that system work for us?

Incidentally, I have also seen local CMHs try to cheap out and run their operation with only NPs, and it just didn't go well. The NPs were stressed out all the time. Our NP colleagues are not insane, they realize they have a giant relative knowledge deficit and the good ones WANT education and supervision.

I don't like or agree with the way the wind is blowing, but we have to admit that there is a massive shortage of psychiatrists, and many of us don't take insurance. Somebody's got to serve the patients, and NPs have stepped up to fill that vacuum whether we like it or not. I don't think we're ever putting the genie back in the bottle, so we should advocate for laws that insist on genuine, high-quality supervision of NPs.

 

[Celexa]

I don't know what the future of Psychiatry writ large is. I don't think that the future of American Healthcare is going in a very good direction in general and so I don't think that Psychiatry as a field is going to escape those pressures. However I don't worry about my own future because everything I see says that there will always be a niche for high quality care. It makes me sad that I don't know that that will be widely available anytime soon. But I don't worry about what's going to happen for my career or the career of my trusted colleagues. I have seen more than enough evidence that when good care is provided people will pay for it. And the irony is that with bad care being so abundant sometimes people don't believe good care exists but when they encounter it they do understand it. In a sad way subpar care just creates more of a market for people who have skills.

 

[Stagg737]

OP, your husband is right. Most of the don't know what they don't know. There are some great NPs out there, but oftentimes the good ones don't want to be practicing without a psychiatrist they can collaborate with. The younger generation of NPs who just want to go out there and be cowboys and practice on their own with minimal education is especially problematic, imo.

From the literally dozens of psych NPs I've worked with in residency and afterwards (both in FPA states), I'd say 75% have no business working without physician supervision and at least 1/3 are so bad that they can be quite dangerous for patients. I regularly see patients come into my ER where the NP has done something egregiously bad like started them on 2 (or more) antipsychotics in their first couple appointments, sometimes when antipsychotics aren't even indicated (PTSD). It's not unique to psych either, I have seen multiple NPs prescribe Nystatin (an anti-fungal) for high cholesterol "because it's a statin".

This is not to just bash NPs, I do think they can have a valuable role in our system when in the correct position, but that involves acting as a physician extender and being supervised, which many do not want. As long as there are large volumes of these individuals practicing, good psychiatrists will always be needed to fix the messes they make in addition to the ongoing (and probably worsening) availability of solid mental health clinicians.

 

[calvnandhobbs68]

I have seen multiple NPs prescribe Nystatin (an anti-fungal) for high cholesterol "because it's a statin".

Damn I don't know whether to laugh or cry about this.

 

[Sushirolls]

Healthcare is going to scat.
I don't recommend my own young relatives, nor will I to my kids go into medicine.
ARNPs and PAs will inherit the medical sphere.
And after the stunt pulled by the CDC, Politicians, and Public Health departments recently, faith in the medical establishment is even further eroded.
I predict much of our health system will start to shake apart. Politicians and health Admin and some societies will start to take notice. But rather than get rid of ARNPs and PAs and reverting to a model that utilizes non-resident trained physicians (medical graduates) or Intern trained/licensed only physicians to replace the labor needs of ARNP/PAs, the powers that be will instead push for more rules, more bureaucracy, more 'laws' that regulate health care practice. Making things worse. The bloat will create a weird defacto government care landscape. There will be some tech, some medicine, some device advances that mitigate this and improve population health as a whole, but only slowly delaying the path we are on. With time, the volume of midlevels and the way care is delivered, my future geriatric self will actually be better off avoiding medical care than seeking it.

I am already preparing myself mentally to die of something that should be treatable, or reduceable in the decades to come - simply because going to the hospital to be treated by the ARNP in ED, to then be punted from "Specialist" ARNP to "specialist" ARNP will be a continued blind referring to the blind, and statistically at some point one is going to really fun up, and I get the iatrogenic harm. It will be a better gamble to avoid medical care than to seek it. This is the future. I hope I am wrong. I hope in 20-30 years people can point to this post and laugh at just how wrong I was, and give a solid roasting.

 

[Celexa]

Healthcare is going to scat.
I don't recommend my own young relatives, nor will I to my kids go into medicine.
ARNPs and PAs will inherit the medical sphere.
And after the stunt pulled by the CDC, Politicians, and Public Health departments recently, faith in the medical establishment is even further eroded.
I predict much of our health system will start to shake apart. Politicians and health Admin and some societies will start to take notice. But rather than get rid of ARNPs and PAs and reverting to a model that utilizes non-resident trained physicians (medical graduates) or Intern trained/licensed only physicians to replace the labor needs of ARNP/PAs, the powers that be will instead push for more rules, more bureaucracy, more 'laws' that regulate health care practice. Making things worse. The bloat will create a weird defacto government care landscape. There will be some tech, some medicine, some device advances that mitigate this and improve population health as a whole, but only slowly delaying the path we are on. With time, the volume of midlevels and the way care is delivered, my future geriatric self will actually be better off avoiding medical care than seeking it.

I am already preparing myself mentally to die of something that should be treatable, or reduceable in the decades to come - simply because going to the hospital to be treated by the ARNP in ED, to then be punted from "Specialist" ARNP to "specialist" ARNP will be a continued blind referring to the blind, and statistically at some point one is going to really fun up, and I get the iatrogenic harm. It will be a better gamble to avoid medical care than to seek it. This is the future. I hope I am wrong. I hope in 20-30 years people can point to this post and laugh at just how wrong I was, and give a solid roasting.

I mean, I'm basically hoping that I retain enough connections to the Ivory Tower to be able to wiggle my way in to be seen by someone who knows what they're doing. But I'm not going to refute your picture of the future in a lot of places.

 

[Sushirolls]

We don't need ARNPs.
We don't need PAs.
I have low hopes for a repeat flexner report to clean house like the early 1900s did.

What we need are either fresh MD/DO graduates who can practice, to in fill their roles - and have an independent license.

Or at worst require an intern year (not needed IMO) trained MD/DO to then practice independently and be candidates to infill those roles.

These MD/DO grads or intern grads can always apply for residencies in years to come if they ever want a career change.

 

[Candidate2017]

I don't think we're ever putting the genie back in the bottle, so we should advocate for laws that insist on genuine, high-quality supervision of NPs.

Who is this "we"? Hospitals, EMR companies, etc. are more well-organized than physicians and spend lots of money lobbying politicians. These entities care about money not quality.

If anything, the government is more likely to pass laws requiring all physicians to supervise 10 NPs as part of the requirement to participate in Medicare. Or better yet, the government can deduct 5% from Medicare payments for any physician who doesn't supervise NPs. Just like they forced EMRs on to us via meaningful use.

As it stands, pretty much every hospital employed physician is already required by their hospital to supervise NPs for little to no compensation.

 

[Sushirolls]

I hope medicare does something like that.
It'll kill the program faster as more people leave in network status.

 

[VA Hopeful Dr]

I hope medicare does something like that.
It'll kill the program faster as more people leave in network status.

Vast majority of medicine can't survive without Medicare.

 

[psychmd03]

I hope for the best plan for the worst. The plan should be to make your money and make moves towards FI quickly so that if the bottom does fall out at least you havea choice to really step back and not become a cog working for 200k supervising 10 NPs

 

[Sushirolls]

Vast majority of medicine can't survive without Medicare.

How Big Box shops are now, perhaps, but you kill off medicare, it will improve access for all other non-medicare insured.

Every surgical specialty in non-certificate of need state will surge as ASC either spring up from ground or get numerous inquiries for practice rights.
Some hospitals wanting to keep their staff around, will look at getting certification not through JCAHO but others like DNS? which I believe [<-- fact check this sentence] don't require participation in CMS like JCAHO does. They'll quickly change their bylaws from requiring Medicaid/medicare to be on staff, and even change from non-profit to for profit if necessary, too. This would be an excellent shake up to get healthcare off the government teet. Besides, as medicare cuts, or lack of increase continues, it will slowly unfold at some point.

 

[comp1]

This OP is truly impressive with the baiting in multiple threads. This stuff about NPs is absolutely and literally classic, one of the "greatest hits." In general, I don't recommend advising searching for old threads because I find new threads important and interesting, even if they tread old ground, but for research purposes you'll see these same worried comments (and even baiting) present over 10 years ago. As back then and even more so now, there are too many patients and not enough providers of all kinds. There is nothing to support this changing beyond anecdotes and a lot to support it continuing. Salaries will continue to remain extremely high and possibly even increase relative to inflation. There are highly competent NPs and highly competent psychiatrists. There are also the reverse of both. The literature generally supports our current workload arrangement for NPs, which remember remains highly profitable for psychiatrists who have in no way had a salary reduction with the addition of NPs. If you think somehow NPs are supremely dangerous, you're going to have to launch some sort of study that supports it cause there are many that support the reverse. I would certainly recommend medicine to people interested in it and psychiatry in particular. There are very, very few salaried jobs regardless of income level that essentially guarantee being placed in the top 3-5% of income earners.

 

[psychma]

This OP is truly impressive with the baiting in multiple threads. This stuff about NPs is absolutely and literally classic, one of the "greatest hits." In general, I don't recommend advising searching for old threads because I find new threads important and interesting, even if they tread old ground, but for research purposes you'll see these same worried comments (and even baiting) present over 10 years ago. As back then and even more so now, there are too many patients and not enough providers of all kinds. There is nothing to support this changing beyond anecdotes and a lot to support it continuing. Salaries will continue to remain extremely high and possibly even increase relative to inflation. There are highly competent NPs and highly competent psychiatrists. There are also the reverse of both. The literature generally supports our current workload arrangement for NPs, which remember remains highly profitable for psychiatrists who have in no way had a salary reduction with the addition of NPs. If you think somehow NPs are supremely dangerous, you're going to have to launch some sort of study that supports it cause there are many that support the reverse. I would certainly recommend medicine to people interested in it and psychiatry in particular. There are very, very few salaried jobs regardless of income level that essentially guarantee being placed in the top 3-5% of income earners.

Just asking because my son is hoping to go into psychiatry. He is an ms1 so who knows. Not trying to bait just curious about the future.

 

[VA Hopeful Dr]

How Big Box shops are now, perhaps, but you kill off medicare, it will improve access for all other non-medicare insured.

Every surgical specialty in non-certificate of need state will surge as ASC either spring up from ground or get numerous inquiries for practice rights.
Some hospitals wanting to keep their staff around, will look at getting certification not through JCAHO but others like DNS? which I believe [<-- fact check this sentence] don't require participation in CMS like JCAHO does. They'll quickly change their bylaws from requiring Medicaid/medicare to be on staff, and even change from non-profit to for profit if necessary, too. This would be an excellent shake up to get healthcare off the government teet. Besides, as medicare cuts, or lack of increase continues, it will slowly unfold at some point.

Spoken like someone who has no clue how this works and even less of a clue how medicine was before Medicare.

 

[annoyedpsychiatrist]

there are already a ton of online shops and psych NPs but still a large amount of openings for MDs. Its hard to find a job that you want in a specific city sometimes sure but the demand is fairly high in our field, PCPs are often not wanting to deal with this and referring to us. Mental health is only getting worse as life becomes more difficult to deal with.

 

[Sushirolls]

Spoken like someone who has no clue how this works and even less of a clue how medicine was before Medicare.

Medicine was better before Medicare. One only needs to travel to countries that don't have an equivalent.
I would love to practice in such an environment.
Notes that are 1/2 half page, hand written, cash pay patients, up front, fraction of the rate, but you make that up in sheer volume.

Medicare, CMS, and how the US would unfurl a universal healthcare is toxic. One positive step forward, 2-3 steps backwards. We need a government exodus out of healthcare.

@VA Hopeful Dr my history on SDN I at least have the decorum to not attack you / denigrate your comments to such a degree of baseness. Correct me if I'm wrong with a history / post review from myself, if I have indeed done that. Here, however, you went straight for a reductionist attack rather than arguing the points of the post. Check yourself, have some decorum.

 

[comp1]

What patient care metrics were better before Medicare? What patient care metrics are superior in countries with similar GDPs but no program similar to or more extensive than Medicare?

 

[RomeoNP]

OP, your husband is right. Most of the don't know what they don't know. There are some great NPs out there, but oftentimes the good ones don't want to be practicing without a psychiatrist they can collaborate with. The younger generation of NPs who just want to go out there and be cowboys and practice on their own with minimal education is especially problematic, imo.

From the literally dozens of psych NPs I've worked with in residency and afterwards (both in FPA states), I'd say 75% have no business working without physician supervision and at least 1/3 are so bad that they can be quite dangerous for patients. I regularly see patients come into my ER where the NP has done something egregiously bad like started them on 2 (or more) antipsychotics in their first couple appointments, sometimes when antipsychotics aren't even indicated (PTSD). It's not unique to psych either, I have seen multiple NPs prescribe Nystatin (an anti-fungal) for high cholesterol "because it's a statin".

This is not to just bash NPs, I do think they can have a valuable role in our system when in the correct position, but that involves acting as a physician extender and being supervised, which many do not want. As long as there are large volumes of these individuals practicing, good psychiatrists will always be needed to fix the messes they make in addition to the ongoing (and probably worsening) availability of solid mental health clinicians.

Usually I avoid these threads because they are unproductive, but very respectfully, I have a very hard time believing the bolded. But I cannot speak for you as this is your anecdote.

 

[WisNeuro]

Usually I avoid these threads because they are unproductive, but very respectfully, I have a very hard time believing the bolded. But I cannot speak for you as this is your anecdote.

In my experience, unfortunately I have no trouble believing the bolded with what I have seen in MH and Neurology setting with such providers.

 

[Sushirolls]

What patient care metrics were better before Medicare? What patient care metrics are superior in countries with similar GDPs but no program similar to or more extensive than Medicare?

To answer your question, there were no care metrics before.
Countries that lack a Medicare equivalent aren't tracking care metrics.
Doing a more educated head to comparison as you may be alluding to, is unlikely to happen.

Bureacracy is a metric that can't really be tracked. Bureacracy is a thing we are all experiencing in different levels and different flavors with different consequences. It could price inflation of health care costs as a hole. It can be access to direct patient care. It can be access to pharmacies. It can be burn out from clinicians and physicians. It can be the shutting down down of psych units because of poor staffing or "not making any money." Bureacracy requirements to RN to MA to LPN ratios, when the task dosn't really need a union BSN, but a MA/LPN.

 

[Sushirolls]

Usually I avoid these threads because they are unproductive, but very respectfully, I have a very hard time believing the bolded. But I cannot speak for you as this is your anecdote.

I wish it wasn't true to.
I wish I was the fool who wasted energy and time on doing medical school and residency, over training, over studying, over debt burden, etc
And the better mouse trap really was the ARNP or even PA route. I wish it was a disruptive training model that simply highlighted a better, faster way to make "providers." Then I'd only have to process my own frustrations, and simply steer any new med students to ARNP/PA paths.

But these moments, these observations are just too frequent.

 

[VA Hopeful Dr]

Medicine was better before Medicare. One only needs to travel to countries that don't have an equivalent.
I would love to practice in such an environment.
Notes that are 1/2 half page, hand written, cash pay patients, up front, fraction of the rate, but you make that up in sheer volume.

Medicare, CMS, and how the US would unfurl a universal healthcare is toxic. One positive step forward, 2-3 steps backwards. We need a government exodus out of healthcare.

@VA Hopeful Dr my history on SDN I at least have the decorum to not attack you / denigrate your comments to such a degree of baseness. Correct me if I'm wrong with a history / post review from myself, if I have indeed done that. Here, however, you went straight for a reductionist attack rather than arguing the points of the post. Check yourself, have some decorum.

Medicare has been a godsend for physicians. Prior to the introduction of Medicare, the average doctor made 2X above the national average. Now us poor FPs are over 4X the national average. And we're one of the lowest paid specialties generally speaking. Neurosurgeons back then averaged 7x the average. Now they're more like 20X the national average.

Admittedly, its more of a nuisance to deal with now than it was in the 80s/90s but it still gives us a bunch of patients who otherwise wouldn't seek care due to the cost. There aren't enough insurance patients for every doctor out there and we charge too much for stuff. This is true even for cash pay stuff. You look at cash-pay imaging/surgery centers and while way cheaper than hospital-owned its still very expensive. Trust me, I did a cash-only practice for several years. Lots of what my patients needed was affordable, lots of it wasn't.

 

[clausewitz2]

To answer your question, there were no care metrics before.
Countries that lack a Medicare equivalent aren't tracking care metrics.
Doing a more educated head to comparison as you may be alluding to, is unlikely to happen.

Bureacracy is a metric that can't really be tracked. Bureacracy is a thing we are all experiencing in different levels and different flavors with different consequences. It could price inflation of health care costs as a hole. It can be access to direct patient care. It can be access to pharmacies. It can be burn out from clinicians and physicians. It can be the shutting down down of psych units because of poor staffing or "not making any money." Bureacracy requirements to RN to MA to LPN ratios, when the task dosn't really need a union BSN, but a MA/LPN.

Please tell me what industrialized country does not have a health bureaucracy of some kind tracking care metrics of one sort of another, whether in the form of an insurance company, a quango, or an actual government department/ministry.

I have been in many countries without a medicare equivalent, and in one of them when I had heat stroke the lovely neighborhood pharmacist offered to give me a saline IV for $20. This was the extent of available local medical care unless you happened to need a particular form of eye surgery that a charitable clinic had been set up to provide by foreign NGOs or were in dire need of the dengue hospital. This is not a system you want.

 

[Merovinge]

Please tell me what industrialized country does not have a health bureaucracy of some kind tracking care metrics of one sort of another, whether in the form of an insurance company, a quango, or an actual government department/ministry.

I have been in many countries without a medicare equivalent, and in one of them when I had heat stroke the lovely neighborhood pharmacist offered to give me a saline IV for $20. This was the extent of available local medical care unless you happened to need a particular form of eye surgery that a charitable clinic had been set up to provide by foreign NGOs or were in dire need of the dengue hospital. This is not a system you want.

Feel like I would really dig a time machine where I could go back in time and travel with you.

 

[comp1]

There were many healthcare metrics collected before Medicare and I'm sure there must be some outliers, but the vast majority of them have dramatically improved. Infant mortality down and inversely lifespans up. Non-healthcare metrics, like seniors in poverty, way down since Medicare was instituted. Bureaucracy can be annoying, but it exists for a reason in a society of hundreds of millions. Similarly, the more centralized a healthcare system is, the better the patient outcomes, pretty uniformly when you account for GDP. I can't speak for physician salaries, but for patient care...Medicare has been amazing.

 

[tr]

There were many healthcare metrics collected before Medicare and I'm sure there must be some outliers, but the vast majority of them have dramatically improved. Infant mortality down and inversely lifespans up. Non-healthcare metrics, like seniors in poverty, way down since Medicare was instituted. Bureaucracy can be annoying, but it exists for a reason in a society of hundreds of millions. Similarly, the more centralized a healthcare system is, the better the patient outcomes, pretty uniformly when you account for GDP. I can't speak for physician salaries, but for patient care...Medicare has been amazing.

What has Medicare got to do with infant mortality? You know a lot of 65 year olds having babies?

 

[VA Hopeful Dr]

What has Medicare got to do with infant mortality? You know a lot of 65 year olds having babies?

Medicare/Medicaid

 

[psychmd03]

Medicine was better before Medicare. One only needs to travel to countries that don't have an equivalent.
I would love to practice in such an environment.
Notes that are 1/2 half page, hand written, cash pay patients, up front, fraction of the rate, but you make that up in sheer volume.

Medicare, CMS, and how the US would unfurl a universal healthcare is toxic. One positive step forward, 2-3 steps backwards. We need a government exodus out of healthcare.

@VA Hopeful Dr my history on SDN I at least have the decorum to not attack you / denigrate your comments to such a degree of baseness. Correct me if I'm wrong with a history / post review from myself, if I have indeed done that. Here, however, you went straight for a reductionist attack rather than arguing the points of the post. Check yourself, have some decorum.

Cash pay for everyone? So, Guess we will just be doing pro bono work the seriously mentally ill since they generally have no jobs and many have no family involvement so no payment coming in from that large swath of our population.

 

[comp1]

Infant mortality tightly correlates with involvement (and therefore survival) of extended family members such as grandparents. And yes, of course, Medicaid is part of the package too.

 

[Sushirolls]

We've already failed the SMI.
The state hospitals need to come back.
The Community mental health centers have been complete failures.
Sample any Blue City homeless population and 20-50% will be legit SMI.
The majority of Psychiatrists already aren't working with SMI anyways.

 

[RomeoNP]

We've already failed the SMI.
The state hospitals need to come back.
The Community mental health centers have been complete failures.
Sample any Blue City homeless population and 20-50% will be legit SMI.
The majority of Psychiatrists already aren't working with SMI anyways.

What could improve outcomes in community mental health setting in your opinion?

 

[Sushirolls]

Nothing. We've had 60+ years to tinker with the concept.

• Liberal declarations of SSD, getting people minimal income... Money still gets blown on drugs, nicotine, or pets.
• People get housing then they complain about it and present to ED often with "group home itis" or disdain for their place for XYZ reason, for those not in group homes.
• ACT teams can only handle a small fraction of people, and even then they are only so effective.
• There is no $ in the game for the CMH patient population, so its not greatly valued, which translates to high no show rates - unless on a controlled substance - then show rates are higher.
• Staff turn over due to personnel quality, low pay, and myriad of other reasons impacting solvency of these agencies. I've seen a for profit mental health maybe do a bit better than average ones, but that isn't even the solution.

The best I've seen are 3 groups. The older schizophrenic who is just tired, plain tired of being admitted over and over to the hospital - still believes nothing is wrong, and no insight into delusions - but willing to take medications because of the recognition that it keeps from going back to the hospital/jail. Second group are those who truly fell on hard times, got enrolled in medicaid, experience the painful bureaucracy and are pushing hard to improve their money/employment to get out of the land of medicaid. Third group are those with ample family support. But the people with ample family support will do well, whether they go to CMH agencies or a Big Box shop. They get their loved ones to appointments, they insure medication compliance, etc. The best intervention we have - is family [que in Republican talking points here]. Our country is barreling in the other direction, dissolution of the traditional family concept, and it of all things is likely the best intervention for SMI. Go figure.

So in defeat, not from a joyous angle of 'look, I have a new shiny idea to solve the worlds problems' I believe a reversion back to large state based Long Term Psychiatric Hospitals is needed.

Have CMH agencies lived up to their vision, the mandates since the 1960s and reduction/closures of state hospitals? Have we made things better? Not just on paper from an angle of civil rights, and the historic abuses of the state hospitals (i.e. non mental health patients sent there for political reasons) but big picture SMI populations? You walk the streets of Portland, Seattle, etc are we doing better? See the news of some tragedy and bits come out from the reporting over ensuing days, nope, not a monster evil person as they title click bait, just another SMI person who was likely off meds and committed act XYZ. Are we really doing better with the CMH concept? I don't believe we are.

**Don't respond to this post, I'll make a separate thread**

 

[WisNeuro]

What could improve outcomes in community mental health setting in your opinion?

Bootstraps, obviously.

 

[whopper]

IMHO there will be further improvements in antidepressant treatment reducing treatment-resistant depression but this still still be a phenomenon.
Add to the problem further advances in technology will create further confusion between what is fantastic delusional and what is not. E.g. cybernetic implants, robots, AI will become a norm.

 

[erg923]

IMHO there will be further improvements in antidepressant treatment reducing treatment-resistant depression but this still still be a phenomenon.
Add to the problem further advances in technology will create further confusion between what is fantastic delusional and what is not. E.g. cybernetic implants, robots, AI will become a norm.

I notice you talk about this alot. And I get, sort of. But I have an aunt who has gotten into all that Q stuff for a while now, and we have basically just realized she's seriously ill (always some subtle signs, but whatev). No one will talk to her anymore and all texts from my mother and her brothers to her are essentially that she should committed to "a home" for some of these fantastical tales about "The Deep State," Trump, Biden, flat earth nonsense, body doubles, the whole 9 yards, etc. Cant say I disagree with them either. To me, she's just freakin nuts.

To me, these are all obvious bizarre delusion, but where do we draw the line?

 

[whopper]

That's what's frustrating with current academia which pretty much controls the DSM.

We are not drawing the line, and we may have to do so. Are we supposed to say "there's no lizard men controlling the government" to an Infowars fan?

I mentioned I suspect I lost patients because I wouldn't cave-in to the COVID vaccine hysteria of a "microchip" in the vaccine. I can't prove it but I've had patients for years and the meeting I tell them there's no microchip, I didn't see them again. So if another physician accommodates this delusion are they doing bad practice?


I had a patient in a jail who had a TBI. Pt did fine with meds except whenever he watched Fox News. Within minutes of watching Fox News he'd go off on a tirade of liberals needing to be kicked out of the country and start screaming. So I told him to stop watching Fox News. No I'm not trying to bash the Right. All cable news has become histrionic, but this specific guy wouldn't follow my recomendations and would need to be placed in isolation once in awhile and right when he got out he'd watch Fox News again and replay the entire incident.

 

[WisNeuro]

That's what's frustrating with current academia which pretty much controls the DSM.

We are not drawing the line, and we may have to do so. Are we supposed to say "there's no lizard men controlling the government" to an Infowars fan?

I mentioned I suspect I lost patients because I wouldn't cave-in to the COVID vaccine hysteria of a "microchip" in the vaccine. I can't prove it but I've had patients for years and the meeting I tell them there's no microchip, I didn't see them again. So if another physician accommodates this delusion are they doing bad practice?

I had a couple people, and patient spouses, balk at my mask requirement during the pandemic. But, every single time when I said "alright, have a good day" and shut the door in their face, they put on the damn masks. I haven't gotten much of the other crazy MAGA/QANON stuff, but then again I'm not really pulling for it as I pretty much want my neuro stuff.

 

[dozitgetchahi]

Healthcare is going to scat.
I don't recommend my own young relatives, nor will I to my kids go into medicine.
ARNPs and PAs will inherit the medical sphere.
And after the stunt pulled by the CDC, Politicians, and Public Health departments recently, faith in the medical establishment is even further eroded.
I predict much of our health system will start to shake apart. Politicians and health Admin and some societies will start to take notice. But rather than get rid of ARNPs and PAs and reverting to a model that utilizes non-resident trained physicians (medical graduates) or Intern trained/licensed only physicians to replace the labor needs of ARNP/PAs, the powers that be will instead push for more rules, more bureaucracy, more 'laws' that regulate health care practice. Making things worse. The bloat will create a weird defacto government care landscape. There will be some tech, some medicine, some device advances that mitigate this and improve population health as a whole, but only slowly delaying the path we are on. With time, the volume of midlevels and the way care is delivered, my future geriatric self will actually be better off avoiding medical care than seeking it.

I am already preparing myself mentally to die of something that should be treatable, or reduceable in the decades to come - simply because going to the hospital to be treated by the ARNP in ED, to then be punted from "Specialist" ARNP to "specialist" ARNP will be a continued blind referring to the blind, and statistically at some point one is going to really fun up, and I get the iatrogenic harm. It will be a better gamble to avoid medical care than to seek it. This is the future. I hope I am wrong. I hope in 20-30 years people can point to this post and laugh at just how wrong I was, and give a solid roasting.

I practice in rural America, and sadly I’d say that the dystopian medical future you envision is basically already here. At my last two jobs (semi rural South and rural Midwest), many of the docs are almost as dull as the NPs and the amount of boneheaded, stupid, harmful decisions I see made on a near daily basis is really astounding (the south was worse than the Midwest, but not by that much).

 

[psychemdoc]

I notice you talk about this alot. And I get, sort of. But I have an aunt who has gotten into all that Q stuff for a while now, and we have basically just realized she's seriously ill (always some subtle signs, but whatev). No one will talk to her anymore and all texts from my mother and her brothers to her are essentially that she should committed to "a home" for some of these fantastical tales about "The Deep State," Trump, Biden, flat earth nonsense, body doubles, the whole 9 yards, etc. Cant say I disagree with them either. To me, she's just freakin nuts.

To me, these are all obvious bizarre delusion, but where do we draw the line?

I have thought about this a lot and I still have no idea what the answer is. People who are no harm to themselves or others is the baseline thinking in society about who needs to be hospitalized. Otherwise we permit you, your family, your friends, and your community to suffer if one is very very unstable but hasn’t “really” gone off the edge somehow. And to me at least it’s very arbitrary. It probably should be arbitrary but it feels almost impossible to pin down. As far as the OP question it seems like we are headed to a place like Sushi says where it is mostly mental health for the masses by mid levels and psychiatrists for the wealthy/connected unless make things change imo.

 

[yoloswagpoop42069]

One future is a HIPPA compliant Chat GPT-10 audio recording device that records your interview and types your goddamn HPI for you.

I wish I could code; that can't be that hard if you are a top tier coder now can it?

As for NPs, ignore them as best as you can. Run far away. Hope that NP mills with little to no clinical experience continue to milk the cash cow, so the NP pool gets so diluted that any patient would be reluctant to go to them.

Or hire a bunch of NPs and milk them for your practice. If you can't beat em, join em I guess. Who knows what the right answer is. Maybe AI will take all of our jobs.

 

[allantois]

Medicine was better before Medicare. One only needs to travel to countries that don't have an equivalent.
I would love to practice in such an environment.
Notes that are 1/2 half page, hand written, cash pay patients, up front, fraction of the rate, but you make that up in sheer volume.

Medicare, CMS, and how the US would unfurl a universal healthcare is toxic. One positive step forward, 2-3 steps backwards. We need a government exodus out of healthcare.

@VA Hopeful Dr my history on SDN I at least have the decorum to not attack you / denigrate your comments to such a degree of baseness. Correct me if I'm wrong with a history / post review from myself, if I have indeed done that. Here, however, you went straight for a reductionist attack rather than arguing the points of the post. Check yourself, have some decorum.

What countries do not have a Medicare equivalent? Zimbabwe?

 

[psychemdoc]

Cash pay for everyone? So, Guess we will just be doing pro bono work the seriously mentally ill since they generally have no jobs and many have no family involvement so no payment coming in from that large swath of our population.

There was always the mentally ill. In previous times it was state institutions, wealthy benefactors, or even community/church supported but not necessarily govts. In all of those scenarios the psychiatrist is useful and paid except maybe with the church run org. Then there’s the other more tragic but probably relatively common solution: prisons/ public sanctions against said people who do not comply with expected social standards. So I personally at least do not think if we got rid of Medicare and Medicaid that we would end up having to work pro bono for all of our patients. Maybe a significant percentage could fall by the way side, but I’m not sure how much different that is than the many who live homeless on the street now and are constantly in the revolving door of various EDs and psych institutions without sufficient medical care/attention.
Just my perception at least.

 

[whopper]

But I have an aunt who has gotten into all that Q stuff for a while now, and we have basically just realized she's seriously ill (always some subtle signs, but whatev).

Forgot to mention this, and this is my theory, I have no hard evidence because I haven't reviewed the hard evidence. When the GOP obtained the Cambridge Analytica data, it pointed them in a direction to then make Cluster A people a voting bloc. For several decades the typical election was a L v R with centrists often times balancing it out. The data IMHO (again this is my speculation) got the hollow Earth, conspiracy-driven, flat-Earth people out to vote cause now they felt, for the first time, someone was resonating with them.

Now there are many other factors as to why the election in 2016 went the way it did and I'm not interested in bringing it up here cause politics as is always leads to people getting ticked off.

Lots of these cluster A types are the reason why a microchip in the vaccine, Hillary having seizures, lizard-people, world conspiracy theories are not only talked about but embraced by a certain political group. In the past mainstream politicians rightfully pushed this stuff off where it should've been-to the garbage bin, but not today.

So when you get a bloc of people who weren't exploited, and now they are very much interested, it can add that needed 1-3% needed to win an election.

Also I'm not trying to make this out like only the R are villains. In the last few years the L pushed several BS things too such as trying to make several men guilty based on sexual accusation alone, the financial exploitation of Black Lives Matter, etc. Just that I'm saying politics in general is nasty and cluster A people are now a voting bloc.

 

[clausewitz2]

Forgot to mention this, and this is my theory, I have no hard evidence because I haven't reviewed the hard evidence. When the GOP obtained the Cambridge Analytica data, it pointed them in a direction to then make Cluster A people a voting bloc. For several decades the typical election was a L v R with centrists often times balancing it out. The data IMHO (again this is my speculation) got the hollow Earth, conspiracy-driven, flat-Earth people out to vote cause now they felt, for the first time, someone was resonating with them.

Now there are many other factors as to why the election in 2016 went the way it did and I'm not interested in bringing it up here cause politics as is always leads to people getting ticked off.

Lots of these cluster A types are the reason why a microchip in the vaccine, Hillary having seizures, lizard-people, world conspiracy theories are not only talked about but embraced by a certain political group. In the past mainstream politicians rightfully pushed this stuff off where it should've been-to the garbage bin, but not today.

So when you get a bloc of people who weren't exploited, and now they are very much interested, it can add that needed 1-3% needed to win an election.

Also I'm not trying to make this out like only the R are villains. In the last few years the L pushed several BS things too such as trying to make several men guilty based on sexual accusation alone, the financial exploitation of Black Lives Matter, etc. Just that I'm saying politics in general is nasty and cluster A people are now a voting bloc.

It's an interesting theory but Richard Hofstadter wrote The Paranoid Style in American Politics in the 60s. This was not a novel insight to the GOP or anyone working in politics.

 

[Sushirolls]

I think it's less that cluster A is being refined into its own voting bloc, but more that the Left and things that have happened in the past 12 years or less has now made this a more sound, reasonable, viable group to belong to.

Forced mask mandates, vaccines, and little to no recognition of natural immunity. Or weighing the consequences of schools, jobs, increased substance abuse, increased child abuse, etc from the fall out of Covid government responses. The authoritarian push, and now as we are seeing the concerted effort to silence/minimize the social media counter points of this group - in what is a free society - cannot be minimized the down stream effect this has on many people.

Schools pushing climate anxiety to an even heighted level of fear. Schools pushing gender issues in ages that simply are just inappropriate and wrong. WA and now CA passing laws that say states can take your kids - take your kids - because of gender ideology. That right there, is an amazing reason to pissed off and paranoid. State sanctioned child abduction. Home schooling once an atypical odd thing to do, now is almost the opposite. If you haven't put your kids in homeschool or private school, what is wrong with you?

Continued push to destroy the economy and personal liberties with getting rid of things like gas stoves? Electric vehicles? Lower water using appliances. Rising taxes. The topped with the cake of printing trillions of dollars to unleash the most economically destructive force known - inflation. Supply chain shortages from Covid and the flashlight shining on the weakness of a global based economy. Not finding diapers or wipes or formula when you have young kids... that leaves a heck of an impression.

Gun Violence as a term. What, no car violence, knife violence, fist violence? And now Biden creates a gun violence commission? Nope, people can see that lie for what it is... using bureaucracy to create the farce of civilian disarmament. All in the context of legalizing the drugs, down grading the criminal code to foster the homeless crisis and unchecked crime crisis. Oh, don't forget the defund the police movement on top of all this. Oh, and letting in illegal immigrants without concern. Encouraging the ATF as an organization to ban pistol braces, really? A pistol brace?

Let's not forget the repeated media lies, which further ignites these flames. Russian dosier was true, not a hoax being pushed - and then years later, oops our bad, we intentionally didn't do our job and pushed that propaganda. Then same thing with hunter biden lap top. Same thing with minimizing clinton emails. Same thing minimizing clinton role allowing a US embassy to be sacked. This list goes on. Without the integrity of the media - this opens up the receptiveness of people to say, well, maybe this conspiracy theory might be true? They did lie to us about these other things?

I've had exposure to paranoid preppers over the years. Always thought they were weird. Fast forward to being Psychiatrist, got a more refined view of the populace from those with true disorders to those basically having a unique hobby. Now, with all these things above going on the in country, people envy these preppers, like dang, you guys were right all along, and are well under way. Simply review the above issues, which isn't even a comprehensive list, and then it starts to make more sense.

This isn't a paranoid bloc. This is a group of people who are upset, shocked, and dismayed by things that are eroding the economy, their freedoms, the way of life they have known, the sense of community that has been but now fractured by the perpetual Racist Monster - despite America being one of the least racist countries on the planet.

So really, if people here and there latch on to a conspiracy theory or two, I get it. I don't blame them. I see it for what it is, a greater symptom of rebuff to liberal left, and the erosion of accountability to politicians who should have resigned (or been jailed), and the perpetual gaslighting of the media.

 

[calvnandhobbs68]

I think it's less that cluster A is being refined into its own voting bloc, but more that the Left and things that have happened in the past 12 years or less has now made this a more sound, reasonable, viable group to belong to.

Forced mask mandates, vaccines, and little to no recognition of natural immunity. Or weighing the consequences of schools, jobs, increased substance abuse, increased child abuse, etc from the fall out of Covid government responses. The authoritarian push, and now as we are seeing the concerted effort to silence/minimize the social media counter points of this group - in what is a free society - cannot be minimized the down stream effect this has on many people.

Schools pushing climate anxiety to an even heighted level of fear. Schools pushing gender issues in ages that simply are just inappropriate and wrong. WA and now CA passing laws that say states can take your kids - take your kids - because of gender ideology. That right there, is an amazing reason to pissed off and paranoid. State sanctioned child abduction. Home schooling once an atypical odd thing to do, now is almost the opposite. If you haven't put your kids in homeschool or private school, what is wrong with you?

Continued push to destroy the economy and personal liberties with getting rid of things like gas stoves? Electric vehicles? Lower water using appliances. Rising taxes. The topped with the cake of printing trillions of dollars to unleash the most economically destructive force known - inflation. Supply chain shortages from Covid and the flashlight shining on the weakness of a global based economy. Not finding diapers or wipes or formula when you have young kids... that leaves a heck of an impression.

Gun Violence as a term. What, no car violence, knife violence, fist violence? And now Biden creates a gun violence commission? Nope, people can see that lie for what it is... using bureaucracy to create the farce of civilian disarmament. All in the context of legalizing the drugs, down grading the criminal code to foster the homeless crisis and unchecked crime crisis. Oh, don't forget the defund the police movement on top of all this. Oh, and letting in illegal immigrants without concern.

Let's not forget the repeated media lies, which further ignites these flames. Russian dosier was true, not a hoax being pushed - and then years later, oops our bad, we intentionally didn't do our job and pushed that propaganda. Then same thing with hunter biden lap top. Same thing with minimizing clinton emails. Same thing minimizing clinton role allowing a US embassy to be sacked. This list goes on. Without the integrity of the media - this opens up the receptiveness of people to say, well, maybe this conspiracy theory might be true? They did lie to us about these other things?

I've had exposure to paranoid preppers over the years. Always thought they were weird. Fast forward to being Psychiatrist, got a more refined view of the populace from those with true disorders to those basically having a unique hobby. Now, with all these things above going on the in country, people envy these preppers, like dang, you guys were right all along, and are well under way. Simply review the above issues, which isn't even a comprehensive list, and then it starts to make more sense.

This isn't a paranoid bloc. This is a group of people who are upset, shocked, and dismayed by things that are eroding the economy, their freedoms, the way of life they have known, the sense of community that has been but now fractured by the perpetual Racist Monster - despite America being one of the least racist countries on the planet.

So really, if people here and there latch on to a conspiracy theory or two, I get it. I don't blame them. I see it for what it is, a greater symptom of rebuff to liberal left, and the erosion of accountability to politicians who should have resigned (or been jailed), and the perpetual gaslighting of the media.

Man this post is a great representation of the very traits that are being discussed. I sometimes wonder if this profile is intentionally trolling as a caricature of a collection of talking points.

Anyway: Online Claims Misrepresent Washington Bill Aimed at Runaway Transgender Youth - FactCheck.org

You're having a hard time keeping this all straight anyway. Is it the "paranoid preppers" who are right or the "schools pushing climate anxiety to an even heighted level of fear"?

 

[Sushirolls]

Our job includes trying to understand people.

Conversely, that also means understanding the climate anxiety people have. The why people erroneously think racism is everywhere. The nuances of Trump Derangement Syndrome. etc. It goes both ways, the reduction of that post to being caricature, trolling, or embossing as cluster A is part of the symptom of the break down of society as a whole. The inability to even role play and try to see things through others eyes. I provided a rudimentary snap shot. Not a detailed thesis with annotated references. Too much to cover. But none the less, a snap shot glimpse for SDN/physicians etc, which are typically left leaning, and likely in an echo chamber of CNN.