Which psychiatry sub-fields are most resistant to mid-level scope creep?

[Osminog]

The number of autonomous psych mid-levels continues to grow. Which areas within psychiatry are most resistant to scope creep?

I've heard that interventional psychiatry (ECT, TMS, ketamine infusions, etc.) will be very safe because it's so procedural. I've also heard that C&A psychiatry is relatively safe due to the reluctance among many mid-levels to pharmacologically manage mental illness in pediatric populations.

Thoughts?

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[wolfvgang22]

I think we have discussed this ad nauseum.

 

[Osminog]

I think we have discussed this ad nauseum.

Fair enough. I've seen a lot of threads about general job market saturation worries, but I haven't been able to find one that specifically addresses the scope creep resistance of particular sub-fields within psychiatry. If anyone has a link to a recent thread that addresses this topic, please feel free to share.

 

[comp1]

It's just a hard question to answer because the premise isn't right. There's plenty of business for everyone, in every subspecialty and no one is projecting otherwise. It's like asking which continent is most likely to fall off the flat earth. I really wish more people spent time as hiring managers...

 

[Osminog]

It's just a hard question to answer because the premise isn't right. There's plenty of business for everyone, in every subspecialty and no one is projecting otherwise. It's like asking which continent is most likely to fall off the flat earth. I really wish more people spent time as hiring managers...

Sure, the job market is looking fine right now. I'm an incoming PGY-1, so I have to care about the relatively distant future. There's no guarantee that the job market will be as favorable 10-20 years from now as more NP diploma mills open and more fully independent NPs start to practice; heck, there are now even some pushes to allow PAs to practice autonomously. Is it really irrational for a psychiatry resident/early-career psychiatrist to take this into consideration when making long-term career plans?

 

[TheRightMedication]

It is a rational concern. However, it's extremely unlikely there will be an analysis with a prediction that is so technically robust as to merit basing your decision making off if it.

Who knows what will happen!

I bet AI eats the mid-level's lunch before it eats ours, anyways.

 

[Merovinge]

Interventional pain (good luck coming from psych but is possible)
CAP (cash pay practice, please don't do this work if you just want money and don't like working with kids)
Forensics (pretty obvious)
Neuropsychiatry (too complicated for midlevels, frankly it's too complicated for 99% of psychiatrists, myself included)
Nothing about TMS or ketamine makes it resistant to mid-levels, I am sure they won't touch ECT but it's very hard to have that be a profitable part of a practice

But that's with 2023 vision and no one can predict the future. I think just focusing on being the best psychiatrist you can be and following what areas actually interest you is still easily the best career advice.

 

[G Sheb]

Nothing is.
It's only a few years before NPs and PAs start invading your conference rooms, eat your lunch and sign your notes.
Get out before it's too late.

 

[Stagg737]

Interventional pain (good luck coming from psych but is possible)
CAP (cash pay practice, please don't do this work if you just want money and don't like working with kids)
Forensics (pretty obvious)
Neuropsychiatry (too complicated for midlevels, frankly it's too complicated for 99% of psychiatrists, myself included)
Nothing about TMS or ketamine makes it resistant to mid-levels, I am sure they won't touch ECT but it's very hard to have that be a profitable part of a practice

But that's with 2023 vision and no one can predict the future. I think just focusing on being the best psychiatrist you can be and following what areas actually interest you is still easily the best career advice.

Agree with most of this, especially that forensics is probably the most untouchable for midlevels d/t lack of foundational education, but it's also no guarantee whatsoever that a good psychiatrist would function well in a forensic setting anyway.

I also agree that TMS and ketamine are not resistant to mid-levels at all either. Mid-levels are already doing medical procedures and staffing ICUs independently of physicians, no reason for ketamine or TMS to be resistant because they are (barely) procedures. I wouldn't be so sure about ECT being resistant either. There's several RNs I work with who are studying for their DNP degrees who openly ask about how they can eventually perform ECT. Frankly, the most liability with ECT is with the anesthesiologist and many places already use CRNAs for ECT.

 

[MacDonaldTriad]

Forensics is a lot about credentials. Mid-Levels would be eaten alive.

I have been saying for a long time that Mid-Levels are only growing because there are needs we are not filling. Many systems would rather have MDs if they could find and attract them.

 

[Merovinge]

Forensics is a lot about credentials. Mid-Levels would be eaten alive.

I have been saying for a long time that Mid-Levels are only growing because there are needs we are not filling. Many systems would rather have MDs if they could find and attract them.

This was/is the case with mental health to some degree, although psychiatry residency slots have dramatically expanded as you know better than I in the past handful of years.

Overall though the mid-level explosion fuels a number of things that are much bigger than a lack of need filled by psychiatrists.
1) Reduced spending on "providers" to pad bottom line of health care organizations, even when NPs cost more than MDs for the same care provided those costs are often shifted by the system to a different bucket such that the HCO still net-profits.
2) Desire for a large swath of the population to play doctor - test scores, intellectual ability, or actual training be damned.
3) Powerful organizations fueling/backing this growth including some physician organizations. We have a dramatically different level of mid-level uptake compared to other Western countries.

 

[clozareal]

With the amount of CAP NP's in my area that charge cash only, I don't think CAP is resistant to this. More NPs say they treat children to adults than general psychiatrists do in my area.

 

[comp1]

As a PGY-1, you should be most focused on finding out what area of psychiatry you enjoy doing. That's going to be so much more important and helpful to you than worrying about NPs in 3 years or 30 years.

 

[wolfvgang22]

As a PGY-1, you should be most focused on finding out what area of psychiatry you enjoy doing. That's going to be so much more important and helpful to you than worrying about NPs in 3 years or 30 years.

Adding on to this, if you're going to switch specialties, now is the time. Maybe Pathology?

 

[TheRightMedication]

Adding on to this, if you're going to switch specialties, now is the time. Maybe Pathology?

That's not bad advice, but psychiatry is a good choice. The academic material is interesting. It has application in your own moment to moment existence. There's a wide variety of jobs to do. You can start your own business and do solo practice easily. It's very helpful work to do for your patients, not that any medical work isnt.

And the pay is pretty good. You can have lenient work hours and make 200k, or a 40- 50 hour week to add 100-200k on top of that. Or take a locums job on a remote oil rig for a while and make even more. And that's just the employed path.

I think a PGY 1 in psych is in a good spot in life.

 

[Atreides]

TMS and ketamine are definitely not resistant to midlevels. The opposite, in fact. Proportionally, there are probably more NP's doing TMS and ketamine than psychiatrists.

CAP is not resistant to midlevels, unfortunately. Same with above, there are proportionally many more NP's doing child psychiatry than non-child psychiatry psychiatrists. Unlike medical school and a psychiatry residency, that online degree trains you "cradle to grave".

 

[Monocles]

Forensics for sure.

Child is well on its way to having more mid-level providers. I think part of is actually supply side incentives - meaning that primary care clinics can bill at a higher level (something about more federal funding for having embedded or integrated MH providers), but economically NO rational psychiatrist would go work under a pediatrician and get skimmed vs. having their own PP, so psych NPs are being created to meet those needs.

 

[clausewitz2]

High end psychotherapy focused on personality disorders in combination with medication management comes to mind. Will call upon a wide range of skills as a psychiatrist and I don't think there are many mid-levels who can hack it for all that long, at least those who aren't happy being benzo+stim +/ opioid machines.

 

[romanticscience]

Echoing @clausewitz2, good/general psychiatric management. Certain people, especially in healthcare, are good judges of quality. People talk. Be one of those providers that you'd recommend to a colleague or family member. Now, you can't build a high-volume clinic with this demographic, but you'll certainly be successful in a solo private practice. I guess the hardest part about this is you have to be good. This doesn't necessarily have to include doing full course psychotherapy; however, psychodynamically-oriented supportive interventions, evidence-based psycho-pharm, and case management really help.

I was particularly intrigued by General Psychiatric Management for BPD (McMain et al., 2009; Gunderson, 2018) when I was in residency. I've found that the GPM model is very pragmatic and applies quite well to a solo private practice psychiatrist! BPD or not!

 

[TheRightMedication]

These guys are right- you have the opportunity in residency to get good psychotherapy training, which can give you the ability to practice at a high level when you combine it with competent psychopharm abilities.

 

[Celexa]

Echoing @clausewitz2, good/general psychiatric management. Certain people, especially in healthcare, are good judges of quality. People talk. Be one of those providers that you'd recommend to a colleague or family member. Now, you can't build a high-volume clinic with this demographic, but you'll certainly be successful in a solo private practice. I guess the hardest part about this is you have to be good. This doesn't necessarily have to include doing full course psychotherapy; however, psychodynamically-oriented supportive interventions, evidence-based psycho-pharm, and case management really help.

I was particularly intrigued by General Psychiatric Management for BPD (McMain et al., 2009; Gunderson, 2018) when I was in residency. I've found that the GPM model is very pragmatic and applies quite well to a solo private practice psychiatrist! BPD or not!

I was going to say this. The protection against mid-level creep is to be actually good at the job.

 

[MacDonaldTriad]

If we refused to "supervise" NPs and didn't back them up on liability, every bad outcome would be a field day for malpractice prosecutors. Insurance companies would raise rates and they wouldn't be cheaper fairly quickly in my opinion. There are good NPs in psych, but most of us have met some that are way too comfortable outside of community norms.

 

[Stagg737]

If we refused to "supervise" NPs and didn't back them up on liability, every bad outcome would be a field day for malpractice prosecutors. Insurance companies would raise rates and they wouldn't be cheaper fairly quickly in my opinion. There are good NPs in psych, but most of us have met some that are way too comfortable outside of community norms.

This trend on the malpractice side is actually happening. I posted an article/link in a different thread a while ago, but while malpractice suites against physicians dropped by about 20% in terms of both volume and payout, rates have increased for NPs. Opening the floodgates to FPA for mid-levels may not actually be a bad thing for physicians in the long-run, though it would certainly do a lot more damage to patient care.

CAP is not resistant to midlevels, unfortunately. Same with above, there are proportionally many more NP's doing child psychiatry than non-child psychiatry psychiatrists. Unlike medical school and a psychiatry residency, that online degree trains you "cradle to grave".

It's not, but it also doesn't mean CAP docs should be worried. I've seen some child patients (mostly in residency) who hat outpt NPs who were just awful. A competent CAP psychiatrist will not have any problems finding patients anytime soon unless the number of fellowship trained child psychiatrists suddenly explodes.

 

[MedMan80]

I was noticing that alot of the barbers in my area are self-employed, requiring appointments to be booked in advance (no pre-payment). If one does good work and is reliable, you will always attract patients, just like the solo barber does. I am worried more about NP's that can do a decent job psychiatrically but then have better bed-side manner vs the average psychiatrist, what do we do then?

 

[Stagg737]

I was noticing that alot of the barbers in my area are self-employed, requiring appointments to be booked in advance (no pre-payment). If one does good work and is reliable, you will always attract patients, just like the solo barber does. I am worried more about NP's that can do a decent job psychiatrically but then have better bed-side manner vs the average psychiatrist, what do we do then?

Until NP schools/training gets a modern-day Flexner report to actually standardize their training, I don't think this is something you'll have to worry about.

 

[Celexa]

I was noticing that alot of the barbers in my area are self-employed, requiring appointments to be booked in advance (no pre-payment). If one does good work and is reliable, you will always attract patients, just like the solo barber does. I am worried more about NP's that can do a decent job psychiatrically but then have better bed-side manner vs the average psychiatrist, what do we do then?

If an NP has a better bedside manner than a psychiatrist the psychiatrist has no one to blame but themselves.

 

[clausewitz2]

If an NP has a better bedside manner than a psychiatrist the psychiatrist has no one to blame but themselves.

Yeah, my gut reaction to this was "git gud."

 

[nexus73]

A local PA bought a TMS machine and is running a clinic with a phantom supervisor somewhere. She wanted me to help because some insurance requires a psychiatrist apparently. As it should honestly. But there is little stopping the entrepreneurial mid levels out there.

 

[Shikima]

Honestly, the only area would be forensics.

 

[Merovinge]

If an NP has a better bedside manner than a psychiatrist the psychiatrist has no one to blame but themselves.

It depends on how you define bedside manner. There are clearly patients for whom not filling Adderall 30 IR TID and Xanax 2mg TID = bad bedside manner. Talking about how tough my life is but how much better it gets with fast acting IR controlled substances while not engaging in any psychotherapy = good bedside manner.

Although I will say that yes generally I do agree that we should have our experience and education shine through during appointments such that the patient/family feel more comfortable with the psychiatrist.

 

[clozareal]

Any sub-fields that makes less money than the average psychiatrist. I kid. But not really.

No one has said these yet:

Geriatric psychiatry - Lots of complexity managing psychiatric conditions and dealing with cognitive concerns (dementia) and physical health co-morbitities.

C-L - again, comorbid medical/psych conditions. You need to understand this, the complex hospital systems, and different specialties and roles in the team.

Academic psychiatry - often requires a level of expertise and knowledge that you can't replace with mid-levels.

Addiction psychiatry - Really need to understand behavior, therapy, how medications react, how substances react. Requires deep pharmacological knowledge.

Eating Disorders - medical complications from this can make both mid-levels and general psychiatrists run.

Neurodevelopmental disorders (autism, intellectual disability, genetic conditions) - requires knowledge about how to diagnose and parse out complex behavioral presentations that most general psychiatrists don't feel comfortable with.

 

[nexus73]

Any sub-fields that makes less money than the average psychiatrist.

No one has said these yet:

Geriatric psychiatry - Lots of complexity managing psychiatric conditions and dealing with cognitive concerns (dementia) and physical health co-morbitities.

C-L - again, comorbid medical/psych conditions. You need to understand this, the complex hospital systems, and different specialties and roles in the team.

Academic psychiatry - often requires a level of expertise and knowledge that you can't replace with mid-levels.

I will say the telehealth company our hospital started using for consults is 90% or more nps, and quality is about what you’d expect, but nobody seems to care.

 

[SpinDktr]

I will say the telehealth company our hospital started using for consults is 90% or more nps, and quality is about what you’d expect, but nobody seems to care.

Sad, but I see this as evidence for a struggling medical system that I wouldn't want to be a part of. I am leaving my current position as the medical director for a geri psych unit, and I think they plan on replacing me with 2 telepsych NP's and a "medical director" basically in name only. I think they are probably going to actually be paying more for the service than my salary, but I don't have the details, and really don't honestly care at this point.

They have no idea what they are in for. I just wish that patients wouldn't have to suffer....to make administrators realize that some of their decisions have really bad consequences.

 

[randomdoc1]

Nearly no area is immune from mid levels. It’s the market and one reason I’m so grateful to have grown up in and be forced to learn essentials of a highly competitive family business market: food service. When the care is high quality from that first phone call to walking out of an encounter, people KNOW. Do better than others, and you are protected. Sure, patients don’t understand medical literature (just like how most restaurant customers don't know a thing about fine cooking). But I’ve noticed high end psychiatric care with good outcomes can draw tons of people. People KNOW when food is good. And that’s how my practice grew. I only see patients 1.5-2 days a week now and am not even 40. Continuing to wind down. Now trying to master HR. Finding and keeping true talent. And I’ll be honest. I’ve seen (rare) LCSWs outdo most psychologists. And I’ve seen psychiatrists deliver terrible care in this office too. Guess who had a packed schedule, who was aching for patients, and who got promoted? It’s about quality. Although I agree those with less training tend to have erm…wider variety in qualities as a provider.

 

[MedMan80]

Nearly no area is immune from mid levels. It’s the market and one reason I’m so grateful to have grown up in and be forced to learn essentials of a highly competitive family business market: food service. When the care is high quality from that first phone call to walking out of an encounter, people KNOW. Do better than others, and you are protected. Sure, patients don’t understand medical literature. But I’ve noticed high end psychiatric care with good outcomes can draw tons of people. And that’s how my practice grew. I only see patients 1.5-2 days a week now and am not even 40. Continuing to wind down. Now trying to master HR. Finding and keeping true talent. And I’ll be honest. I’ve seen (rare) LCSWs outdo most psychologists. And I’ve seen psychiatrists deliver terrible care in this office too. Guess who had a packed schedule, who was aching for patients, and who got promoted? It’s about quality. Although I agree those with less training tend to have erm…wider variety in qualities as a provider.

Good to see people thriving with this model.

 

[randomdoc1]

Also, the more we free ourselves from chaotic systems and thrive, the more leverage we get as physicians. I forgot to throw in, whenever you can, do not agree to supervise midlevels. At least, I wouldn't in those type of settings. Perhaps certain individual models/circumstances make it a decent working system, but most of the ones I've seen are not. And I sure as heck have rejected innumerable requests for me to precept PAs/NPs.

All with the exception of one. She worked at this office for a year as a TMS tech and admin assistant. She was the most outstanding employee in this office, many spontaneous compliments from patients (which was replicable during her derm rotation--she got a 5 star google review at the clinic she rotated at and the dermatologist offered her a job too; it's cosmetic derm too, so lotsa $$$) and literally drove in an additional 50k in a year for me from her productivity and her clinical intuition is excellent. I recommended medical school for her, but sadly she pursued PA school (nothing against the concept of a PA although most curriculums do a poor job but that speaks more to who designed it, but I think she could have done great in med school and gotten all the credit she deserved). I precepted her psychiatry rotation. Not surprisingly, she did fantastically on her end of rotation exam. I still kind of mentor her and was honest in saying I think her PA curriculum like most, did not do her service. She took my advice to pursue a fellowship which will serve her well in leveraging better job offers and most of all make her a far better provider than other midlevel peers. I told her if she decided to do a psychiatry fellowship and agreed to two years of supervision after, she has a cush job here.

 

[randomdoc1]

The number of autonomous psych mid-levels continues to grow. Which areas within psychiatry are most resistant to scope creep?

I've heard that interventional psychiatry (ECT, TMS, ketamine infusions, etc.) will be very safe because it's so procedural. I've also heard that C&A psychiatry is relatively safe due to the reluctance among many mid-levels to pharmacologically manage mental illness in pediatric populations.

Thoughts?

Where there is money to be made, there will always be someone trying to compete ; ). lol

Even in the pet industry. I hear foxes are getting whiff that cats and dogs have a good gig. So they are showing physical signs of domestication. Even pets aren't safe. Seriously!

 

[liquidshadow22]

Forensics is the main one. Definitely too difficult for a midlevel but also too difficult for most psychiatrists

 

[splik]

Forensics is the main one. Definitely too difficult for a midlevel but also too difficult for most psychiatrists

Forensic psychiatrists compete with psychologists for cases, which depresses expert witness rates compared with other medical specialties. Many cases can be done well by either. This is one reason it is not uncommon for forensic psychiatrists to partner with a psychologist. Psychologists have the advantage of being proficient in psychological testing. Psychiatrists bring the medical background and psychopharm knowledge, but it's not needed in many cases. There are cases where social workers or masters level therapists are the psychiatric expert witness too, so it is not a stretch to imagine a time when psych NPs become more common doing expert witness work. I did one case where the opposing attorney claimed I was less qualified than their social worker expert to opine on severe mental illness lol. While lawyers with deep pockets will want the best expert, plaintiff attorneys are often cost conscious and nurses are often seen as trustworthy (often more than physicians) to the public who make up juries.

Also psych NPs do expert witness work in malpractice cases involving others NPs.

 

[G Sheb]

I'd push back a little bit on forensics being 'extra special'.
If there's a time where NPs are thought to be equally qualified as psychiatrists, I don't see why they wouldn't compete in the reputation game in the courts. So it's a bit circular here. The reason why psychiatrists have an advantage in the courts is because as an MD you have a better expert reputation.

In any case, this is all ridiculous.
This forum feels sometimes like a dumping place for neuroticism.
It's like chatgpt vs nurses at this point.
By the time NPs take all of our jobs, chat GPT would have taken theirs.

 

[Merovinge]

I'd push back a little bit on forensics being 'extra special'.
If there's a time where NPs are thought to be equally qualified as psychiatrists, I don't see why they wouldn't compete in the reputation game in the courts. So it's a bit circular here. The reason why psychiatrists have an advantage in the courts is because as an MD you have a better expert reputation.

In any case, this is all ridiculous.
This forum feels sometimes like a dumping place for neuroticism.
It's like chatgpt vs nurses at this point.
By the time NPs take all of our jobs, chat GPT would have taken theirs.

Whoa whoa, I hope you aren't implying psychiatrists have a reputation for neuroticism, how completely unfounded an accusation .