$500 an hour not bad for a psych NP

[mememaster9000]

99709 Psychiatrists - Psychiatrist 99709 - Psychiatric Nurses 99709

Find Psychiatrists in 99709 or 99709 Psychiatric Nurses.

www.psychologytoday.com

I was looking at psych profiles in the 20 or so states that allow nurse practitioners to practice independently, it was surprising to see that $250-$300 an hour was the average rate advertised ($125-150 for a 20-30 minute follow up). Also surprising that some physicians are charging less than the average nurse practitioner and only a few charging more. What's the incentive to train for an extra 5 years?

---

Members don't see this ad.

 

[deleted480308]

99709 Psychiatrists - Psychiatrist 99709 - Psychiatric Nurses 99709

Find Psychiatrists in 99709 or 99709 Psychiatric Nurses.

www.psychologytoday.com

I was looking at psych profiles in the 20 or so states that allow nurse practitioners to practice independently, it was surprising to see that $250-$300 an hour was the average rate advertised ($125-150 for a 20-30 minute follow up). Also surprising that some physicians are charging less than the average nurse practitioner and only a few charging more. What's the incentive to train for an extra 5 years?

the incentive is to give the patient appropriate level of care

 

[mememaster9000]

the incentive is to give the patient appropriate level of care

"Some schools recommend that applicants have at least one year of previous nursing experience; however, this is rarely a requirement. As a result, many BSN-graduates are opting to go directly to NP school without practicing as an RN first." source: Nurse Practitioner Requirements by Program & NP Recertification

1000 clinical hours required to practice independently with no restriction that the training must be in future specialty of practice. How Does NP Practice Authority Vary By State?

So a nurse practitioner can do BSN 4 years + (no nurse work experience required) + NP program 2 years (classroom time and 1000 hours, roughly, 6 months of nonspecific clinical training). Could be age 24 with practically no experience and go hang a shingle as the new cash only psych in town.

I absolutely agree that we should give the patient the appropriate level of care, but if law makers in this many states are ignorant or morally bankrupt enough to allow this to happen, many nurse practitioners are seeing the opportunity and taking advantage, then how do you expect the average citizen to realize they are not getting appropriate care?

We can simply look at the world of marketing and realize the consumer is not intelligent. There exist millionaire naturopaths who sell snake oils and whose only skill is excellent salesmanship. If the 24 year old nurse practitioner of my example is equivalently equipped with the manipulation skills to get patients in the door and throwing down that money, the state fully allows it. At least there exist restrictions on what the naturopath can say or do. The nurse practitioner on the other hand gets the same unrestricted access to practice medicine as an MD/DO with at minimum 4 years less education and training.

 

[deleted480308]

"Some schools recommend that applicants have at least one year of previous nursing experience; however, this is rarely a requirement. As a result, many BSN-graduates are opting to go directly to NP school without practicing as an RN first." source: Nurse Practitioner Requirements by Program & NP Recertification

1000 clinical hours required to practice independently with no restriction that the training must be in future specialty of practice. How Does NP Practice Authority Vary By State?

So a nurse practitioner can do BSN 4 years + (no nurse work experience required) + NP program 2 years (classroom time and 1000 hours, roughly, 6 months of nonspecific clinical training). Could be age 24 with practically no experience and go hang a shingle as the new cash only psych in town.

I absolutely agree that we should give the patient the appropriate level of care, but if law makers in this many states are ignorant or morally bankrupt enough to allow this to happen, many nurse practitioners are seeing the opportunity and taking advantage, then how do you expect the average citizen to realize they are not getting appropriate care?

We can simply look at the world of marketing and realize the consumer is not intelligent. There exist millionaire naturopaths who sell snake oils and whose only skill is excellent salesmanship. If the 24 year old nurse practitioner of my example is equivalently equipped with the manipulation skills to get patients in the door and throwing down that money, the state fully allows it. At least there exist restrictions on what the naturopath can say or do. The nurse practitioner on the other hand gets the same unrestricted access to practice medicine as an MD/DO with at minimum 4 years less education and training.

you are preaching to the choir, but now you are asking a different question

 

[calvnandhobbs68]

Here’s the thing though. This only works in areas where there’s literally NOBODY else for psych. In fact, if I wanted to live in where these NPs are living right now, Id run my ass over there ASAP. If you’re the kind of person who’s paying 500 bucks an hour out of pocket (or 200-300 out of pocket), you’re gonna be a much more discerning customer than your average Joe at the CMHC. Who do you think the person who’s paying this kind of money is going to rather see, an NP or MD/DO?


As for the issue about physicians charging less, they’re always welcome to charge more, nobody’s stopping them in the private pay world. But what you might find is that it gets more difficult to fill a practice if you go from 250 to 350 an hour.
Also this is again what they charge...it’s like eBay. Just cause the beanie baby is listed for 5000 bucks doesn’t mean anyone is actually gonna buy it for that...or they might. They may or may not actually have many patients.

 

[NickNaylor]

As @calvnandhobbs68 said, the person that is willing and able to pay $500/hr for psychiatric follow-up is unlikely to be willing to see a midlevel unless there are literally no other options. Frankly I would be surprised if a NP is able to come even close to filling a practice with that kind of fee. We also can't underestimate the difference between the perception of good care and actually good care. Patients are not trained clinicians, and they generally do not have the level of knowledge necessary to evaluate if they're actually receiving quality of care. However, if they feel like the person they're seeing is actually paying attention to them and is responsive to their concerns, that my be more important to them than the fact that their medications are a complete mess. Medicine is a service profession: the perception of what is received is arguably more important than what is actually received from the perspective of patients.

 

[Jules A]

The no RN experience should and would be an easy hard stop.

As for the OP example welp she had me at Adderall...I mean ADHD, lol. Since she is in network with multiple insurance companies it would be unlikely she is getting much if any cash. Even with respected psychiatrists in affluent areas most patients would naturally opt to use their insurance if the provider accepts it. The $550 is also likely not an hourly rate but the 90 minute intake? Still a high rate and for those psychiatrists who aren't negotiating or requiring appropriate compensation something to consider.

 

[clausewitz2]

The no RN experience should and would be an easy hard stop.

As for the OP example welp she had me at Adderall...I mean ADHD, lol. Since she is in network with multiple insurance companies it would be unlikely she is getting much if any cash. Even with respected psychiatrists in affluent areas most patients would naturally opt to use their insurance if the provider accepts it. The $550 is also likely not an hourly rate but the 90 minute intake? Still a high rate and for those psychiatrists who aren't negotiating or requiring appropriate compensation something to consider.

Yeah my suspicion is this person basically is as full as they really want to be taking insurance (no surprise given Fairbanks, AK is not a major hub of North American psychiatry) but this notional cash rate represents the marginal utility of working more.

In other words, "here's what it would take to convince me to take on an extra patient"

 

[NickNaylor]

Yeah my suspicion is this person basically is as full as they really want to be taking insurance (no surprise given Fairbanks, AK is not a major hub of North American psychiatry) but this notional cash rate represents the marginal utility of working more.

In other words, "here's what it would take to convince me to take on an extra patient"

Exactly. I'm guessing this person probably has another side hustle and uses cash-paying patients as another source of income.

 

[Mad Jack]

"Some schools recommend that applicants have at least one year of previous nursing experience; however, this is rarely a requirement. As a result, many BSN-graduates are opting to go directly to NP school without practicing as an RN first." source: Nurse Practitioner Requirements by Program & NP Recertification

1000 clinical hours required to practice independently with no restriction that the training must be in future specialty of practice. How Does NP Practice Authority Vary By State?

So a nurse practitioner can do BSN 4 years + (no nurse work experience required) + NP program 2 years (classroom time and 1000 hours, roughly, 6 months of nonspecific clinical training). Could be age 24 with practically no experience and go hang a shingle as the new cash only psych in town.

I absolutely agree that we should give the patient the appropriate level of care, but if law makers in this many states are ignorant or morally bankrupt enough to allow this to happen, many nurse practitioners are seeing the opportunity and taking advantage, then how do you expect the average citizen to realize they are not getting appropriate care?

We can simply look at the world of marketing and realize the consumer is not intelligent. There exist millionaire naturopaths who sell snake oils and whose only skill is excellent salesmanship. If the 24 year old nurse practitioner of my example is equivalently equipped with the manipulation skills to get patients in the door and throwing down that money, the state fully allows it. At least there exist restrictions on what the naturopath can say or do. The nurse practitioner on the other hand gets the same unrestricted access to practice medicine as an MD/DO with at minimum 4 years less education and training.

If patients have a nurse practitioner charging $500/hr and a physician charging $300/hr in the same area, more often than not the physician is going to get the business. There probably just isn't anyone else in the area offering services. You'd be shocked at the number of patients I see that come my way because they've had what they view to be seriously lacking care provided by NPs or PAs. Psychiatry is very challenging, and it is impossible to be fully competent for full-scope independent practice after 1000 hours of clinical training. Patients recognize and appreciate this, particularly the ones willing to pay cash.

If you're concerned about it though, go get yourself a JD and start ambulance chasing after independent midlevels. I guarantee it will be a booming market in coming years.

 

[downwithDTB]

"Some schools recommend that applicants have at least one year of previous nursing experience; however, this is rarely a requirement. As a result, many BSN-graduates are opting to go directly to NP school without practicing as an RN first."

So a nurse practitioner can do BSN 4 years + (no nurse work experience required) + NP program 2 years (classroom time and 1000 hours, roughly, 6 months of nonspecific clinical training).

I'm not sure that we should be placing any emphasis on the value of experience as an RN. The RNs to MDs that I know are wonderful MDs and humans but I don't feel as though they were that far ahead of their peers in medical school. Work as an RN, EMT, scientist, business person, lawyer, poet, ect. can certainly flavor an MD and provide supplemental skill sets. Nursing practice (or those things above), however, is not medicine and doesn't prepare one to practice medicine nor does it adequately substitute for medicine.

I would point this out and say, "...and the claim that NPs have nursing is experience prior to NP school is false because many don't."

Also, you've overstated NP training requirements. The minimum is only 500 hours of unstructured shadowing, not 1000. I definitely did 1000 hours in significantly less than 6 months in ms3, ms4 and pgy1 & 2. Further, no classroom time is required, many schools are 100% online. You can complete some schools in ~1.5 years and many people work full time during that.

As @calvnandhobbs68 said, the person that is willing and able to pay $500/hr for psychiatric follow-up is unlikely to be willing to see a midlevel unless there are literally no other options.

I'm not entirely sure that this is true. We are trained to treat patients by recommending things that will help their health over time scales of years. Most healthcare consumers want "to be heard and understood" and to fell better on a time scale of days. That typically means that "nothing is my fault."

Clinicians who actively collude with pathology and always provide quick fixes (Xanax and percs) that may be detrimental and never challenge patients to change their behavior may be loved and compensated through the roof even though the patient just slowly gets worse and worse under their inappropriate care, Conrad Murray style. Luckily for NPs, you can give "listen" to people and give them some reasonably safe meds whether or not they are indicated and not clearly do any harm.

 

[mememaster9000]

If patients have a nurse practitioner charging $500/hr and a physician charging $300/hr in the same area, more often than not the physician is going to get the business. There probably just isn't anyone else in the area offering services. You'd be shocked at the number of patients I see that come my way because they've had what they view to be seriously lacking care provided by NPs or PAs. Psychiatry is very challenging, and it is impossible to be fully competent for full-scope independent practice after 1000 hours of clinical training. Patients recognize and appreciate this, particularly the ones willing to pay cash.

If you're concerned about it though, go get yourself a JD and start ambulance chasing after independent midlevels. I guarantee it will be a booming market in coming years.

I like your idea of getting a JD to sue independent midlevels. But what about the big fish who created the problem. Is it possible to sue the lawmakers themselves for creating the laws that lead to the general public being harmed?

 

[Mad Jack]

I like your idea of getting a JD to sue independent midlevels. But what about the big fish who created the problem. Is it possible to sue the lawmakers themselves for creating the laws that lead to the general public being harmed?

Sent from my Moto G (5) Plus using SDN mobile

You can't be sued for making the law, only falling afoul of it

 

[Mad Jack]

I'm not sure that we should be placing any emphasis on the value of experience as an RN. The RNs to MDs that I know are wonderful MDs and humans but I don't feel as though they were that far ahead of their peers in medical school. Work as an RN, EMT, scientist, business person, lawyer, poet, ect. can certainly flavor an MD and provide supplemental skill sets. Nursing practice (or those things above), however, is not medicine and doesn't prepare one to practice medicine nor does it adequately substitute for medicine.

I would point this out and say, "...and the claim that NPs have nursing is experience prior to NP school is false because many don't."

Also, you've overstated NP training requirements. The minimum is only 500 hours of unstructured shadowing, not 1000. I definitely did 1000 hours in significantly less than 6 months in ms3, ms4 and pgy1 & 2. Further, no classroom time is required, many schools are 100% online. You can complete some schools in ~1.5 years and many people work full time during that.



I'm not entirely sure that this is true. We are trained to treat patients by recommending things that will help their health over time scales of years. Most healthcare consumers want "to be heard and understood" and to fell better on a time scale of days. That typically means that "nothing is my fault."

Clinicians who actively collude with pathology and always provide quick fixes (Xanax and percs) that may be detrimental and never challenge patients to change their behavior may be loved and compensated through the roof even though the patient just slowly gets worse and worse under their inappropriate care, Conrad Murray style. Luckily for NPs, you can give "listen" to people and give them some reasonably safe meds whether or not they are indicated and not clearly do any harm.

For FNPs, it's 650 hours I believe. It varies by the type of NP. I know CRNAs require around 2,000 hours, but can't say for certain how much experience PMHNPs get, but one program showed 620 hours, far from ideal. FNPs shouldn't be working in psych, their education with regard to psychiatry is a few weeks at best in NP school, while PMHNPs are at least focused entirely on psych.

 

[splik]

For FNPs, it's 650 hours I believe. It varies by the type of NP. I know CRNAs require around 2,000 hours, but can't say for certain how much experience PMHNPs get, but one program showed 620 hours, far from ideal. FNPs shouldn't be working in psych, their education with regard to psychiatry is a few weeks at best in NP school, while PMHNPs are at least focused entirely on psych.

most NPs working in psych ARE FNPs!

 

[Mad Jack]

most NPs working in psych ARE FNPs!

I'm aware, and it's a tragedy. 4-6 weeks of half-assed outpatient psychiatry under a NP preceptor isn't enough to prescribe anything safely. PMHNPs also are ill equipped, but not as shamefully so

 

[downwithDTB]

For FNPs, it's 650 hours I believe. It varies by the type of NP. I know CRNAs require around 2,000 hours, but can't say for certain how much experience PMHNPs get, but one program showed 620 hours, far from ideal. FNPs shouldn't be working in psych, their education with regard to psychiatry is a few weeks at best in NP school, while PMHNPs are at least focused entirely on psych.

Nursing education or even medical education focused entirely on psych is completely inadequate to practice psychiatry. The pathophysiology of all organ systems AND complex understanding of all areas of medicine is essential. I use my surgery, ob, medicine, ect., every single day in general outpatient practice. Just like internal medicine training is insufficient to practice medicine, psychiatry training is inadequate to practice psychiatry.

 

[mememaster9000]

You can't be sued for making the law, only falling afoul of it

It's sad that politicians are immune to consequences especially in states where they let naturopaths practice medicine. At the rate we are going everyone will be able to practice medicine as long as they have bribes for politicians.

 

[mememaster9000]

For FNPs, it's 650 hours I believe. It varies by the type of NP. I know CRNAs require around 2,000 hours, but can't say for certain how much experience PMHNPs get, but one program showed 620 hours, far from ideal. FNPs shouldn't be working in psych, their education with regard to psychiatry is a few weeks at best in NP school, while PMHNPs are at least focused entirely on psych.

If they only need 650 hours and an MS3 will get around 3,000 hours then why can't a medical student drop out of medical school after 3rd year and start practicing independently like an NP? We just have to make up a stupid slogan like "practicing at the top of our education" like NPs say. Then after 4th year a medical student has around 6,000 hours but still has to do at least 1 year of residency for a general medical license, why? Both 3rd and 4th year medical students are better trained than NPs who get to go make bank in rural independent practice states. How can politicians give practice rights to NPs and naturopaths and who knows who else and deny 3rd and 4th year medical student?

 

[Mad Jack]

Nursing education or even medical education focused entirely on psych is completely inadequate to practice psychiatry. The pathophysiology of all organ systems AND complex understanding of all areas of medicine is essential. I use my surgery, ob, medicine, ect., every single day in general outpatient practice. Just like internal medicine training is insufficient to practice medicine, psychiatry training is inadequate to practice psychiatry.

Really kind of beside the point, but yeah, that's why psychiatrists are physicians first and psychiatrists second. Nurses get inadequate everything.

 

[Mad Jack]

If they only need 650 hours and an MS3 will get around 3,000 hours then why can't a medical student drop out of medical school after 3rd year and start practicing independently like an NP? We just have to make up a stupid slogan like "practicing at the top of our education" like NPs say. Then after 4th year a medical student has around 6,000 hours but still has to do at least 1 year of residency for a general medical license, why? Both 3rd and 4th year medical students are better trained than NPs who get to go make bank in rural independent practice states. How can politicians give practice rights to NPs and naturopaths and who knows who else and deny 3rd and 4th year medical student?

Quality control. I certainly wasn't competent for independent practice of any sort after they handed me my diploma, and I doubt most people are. Just because other fields are throwing quality out the window doesn't mean that we should follow.

 

[mememaster9000]

Quality control. I certainly wasn't competent for independent practice of any sort after they handed me my diploma, and I doubt most people are. Just because other fields are throwing quality out the window doesn't mean that we should follow.

What's the point of quality control when other professions can get equal rights under the law without being held to the same standards? I just don't see how physicians can just keep doing the same moral grand standing and pretend the world is going to recognize their virtues eventually. We see the opposite trend happening in real life. The hate for physicians grows daily and the length of training just keeps increasing with more and more fellowships being required in various specialties. While more states allow NPs and naturopaths to have physician practice rights. The more we focus on quality control the greater the physician shortage becomes and then politicians use that as an excuse to destroy our profession. Physicians are like the embodiment of the double PhD who has done three post docs and still can't earn more than an engineer with a bachelor degree. At what point do you come to realize no one cares how much you know the real world doesn't care and doesn't appreciate you? Have you guys not seen how much hate psychiatrists get in general? It's likely to be the least respected medical specialty. The fact that to the lay person it just looks like you throw pills at problems and hope they get better. NPs obviously think that's the case. That's why they are so quick to jump into independent private practice and compete with you despite their total lack of training. Whereas a procedural specialty gets very little competition from NPs and naturopaths because the results are fairly obvious and the adverse effects are immediate when someone does it wrong. A naturopath can easily prescribe turmeric for depression and never be held responsible if it doesn't work. They will just point out how sometimes the antidepressant medications psychiatrists prescribe don't work either. Then you are left debating efficacy based on statistics in a study that politicians, naturopaths, NPs, and the general public can't even comprehend. That's why we aren't taken seriously our education doesn't mean anything when only the people who have equal education can understand us and evaluate what we do. How do you guys continue thinking the future is going to somehow reverse trend and get better when it's obvious what direction we have been heading for years? Even intelligent people like Steve Jobs didn't believe in the training and education of oncologists so much so that he chose alternative medicine instead. Imagine if he was mentally ill, do you think he would choose a real psychiatrist or a faker?

 

[downwithDTB]

Her heart is in the right place, but to think I have 4 more years of training and she’ll be done in 3 months is mind blowing to me.

Is her heart really in the right place if she is willing to skimp out on education and go straight to treating people? Seems like her heart is in her pocket.

 

[Sushirolls]

The point of quality control is to still be standing when the flood waters rise. Early 1900's or so when there was the Flexner report and it cleaned house thru the medical establishment. Perhaps another Flexner report will swing around in the next 10, 20, 30 years or so. All the PA and ARNP schools could be shut down, and states will have glaring data to re-adjust their medical licensure.

It's also something that has meaning, even if most people don't understand. So perhaps, at least in Psychiatry, the future is simply an outpatient cash practice as the medical system crumbles under political entropy. Or perhaps health care and physicians collapse under the political entropy. We wouldn't be the first profession to suffer such a future. Look at furniture, who goes to a master carpenter for their bed, chairs or tables? People gravitate towards IKEA, or if they do buy something higher quality its a pressed particle board in forms and also mass produced despite its artistic pattern. Amish builders and the very rare carpenter have a tiny fraction of the wood furniture business.

Society, may simply say they want IKEA healthcare and are willing to accept the consequences. So be it.

The only real way to fight the ARNP midlevel flood is to flood the market with DO/MD grads, and grant them privileges after an intern year or better yet after med school for independent practice. Otherwise another Flexner report, which I'm not holding my breath on.

We have a medical license because society says it was important to regulate who can and can't practice medicine. Society can also say its no longer important and anybody can. It's a piece of legislation, and well legislation changes. We might just have to differentiate ourselves from Aunt Sussie saying she cures all, a Natropath, an ARNP, and burn out EM doc changing careers, and actual Psychiatrist Expert. One positive of this, is hopefully the people who actually walk in your door TRULY, ACTUALLY want to be there and want your advice, and aren't doing it for someone else or because their insurance makes it just a $20 copay. In this less ideal future, people will likely only pay cash, and if willing to pay cash, they'll likely listen to professional recommendations more.

 

[Jules A]

Is her heart really in the right place if she is willing to skimp out on education and go straight to treating people? Seems like her heart is in her pocket.

In all fairness there seems to be quite the bill of goods being sold by universities who encourage students to remain in school, without ever having worked as a RN until they are "doctors". Not that we all shouldn't be aware of our own limitations but generally speaking people don't know what they don't know.

 

[mememaster9000]

The point of quality control is to still be standing when the flood waters rise. Early 1900's or so when there was the Flexner report and it cleaned house thru the medical establishment. Perhaps another Flexner report will swing around in the next 10, 20, 30 years or so. All the PA and ARNP schools could be shut down, and states will have glaring data to re-adjust their medical licensure.

It's also something that has meaning, even if most people don't understand. So perhaps, at least in Psychiatry, the future is simply an outpatient cash practice as the medical system crumbles under political entropy. Or perhaps health care and physicians collapse under the political entropy. We wouldn't be the first profession to suffer such a future. Look at furniture, who goes to a master carpenter for their bed, chairs or tables? People gravitate towards IKEA, or if they do buy something higher quality its a pressed particle board in forms and also mass produced despite its artistic pattern. Amish builders and the very rare carpenter have a tiny fraction of the wood furniture business.

Society, may simply say they want IKEA healthcare and are willing to accept the consequences. So be it.

The only real way to fight the ARNP midlevel flood is to flood the market with DO/MD grads, and grant them privileges after an intern year or better yet after med school for independent practice. Otherwise another Flexner report, which I'm not holding my breath on.

We have a medical license because society says it was important to regulate who can and can't practice medicine. Society can also say its no longer important and anybody can. It's a piece of legislation, and well legislation changes. We might just have to differentiate ourselves from Aunt Sussie saying she cures all, a Natropath, an ARNP, and burn out EM doc changing careers, and actual Psychiatrist Expert. One positive of this, is hopefully the people who actually walk in your door TRULY, ACTUALLY want to be there and want your advice, and aren't doing it for someone else or because their insurance makes it just a $20 copay. In this less ideal future, people will likely only pay cash, and if willing to pay cash, they'll likely listen to professional recommendations more.

I appreciate your comments. I just feel discouraged about it all. When I talk to my medical school classmates about NPs they never believe me when I tell them how much NPs can charge in private practice. Then I show them psychologytoday profiles of psych NPs and everyone is absolutely shocked. They seem to think NPs have to be hired and whoever does the hiring will make sure the NPs are trained well. But NPs don't have to be hired in 21 states and more medical students need to be shown that these independent private practice NPs are making a lot of money because patients are actually going to them to see them.

The situation is dire and while you are probably right that if we just focus on doing the right thing maybe the political climate will swing back in our favor and physicians will be okay. But to me that feels very defeatist. I feel like instead we need to actually fight back and stop being so passive. Truly unite as a profession and stop this craziness. If we are just going to keep on being passive I'm going to have to become a surgeon instead of a psychiatrist. Since apparently it's every specialty for themselves when it comes to fighting midlevel independence.

 

[adaptation1]

Are you going to advocate and lead us in this effort? Kudos to you!

 

[Mad Jack]

I appreciate your comments. I just feel discouraged about it all. When I talk to my medical school classmates about NPs they never believe me when I tell them how much NPs can charge in private practice. Then I show them psychologytoday profiles of psych NPs and everyone is absolutely shocked. They seem to think NPs have to be hired and whoever does the hiring will make sure the NPs are trained well. But NPs don't have to be hired in 21 states and more medical students need to be shown that these independent private practice NPs are making a lot of money because patients are actually going to them to see them.

The situation is dire and while you are probably right that if we just focus on doing the right thing maybe the political climate will swing back in our favor and physicians will be okay. But to me that feels very defeatist. I feel like instead we need to actually fight back and stop being so passive. Truly unite as a profession and stop this craziness. If we are just going to keep on being passive I'm going to have to become a surgeon instead of a psychiatrist. Since apparently it's every specialty for themselves when it comes to fighting midlevel independence.

Oh noooo, he's gonna be a surgeon, he's too afraid of competition and insecure in his own ability to stand out as an exceptional provider! We're gonna lose him!

You seem more bothered by what other people can make than what you can make for yourself. Seems like a rather unhealthy mindset. You should focus on finding a career you enjoy that will pay enough for you to get by.

And trust me, there's plenty of room for good psychiatrists and there will be for the remainder of your working lifetime. We provide a qualitative difference to our patients that many appreciate and are willing to pay a differential for. If you think of psychiatry as different people making the same widgets with different credentials, you've already misunderstood the game.

 

[Sushirolls]

I appreciate your comments. I just feel discouraged about it all. When I talk to my medical school classmates about NPs they never believe me when I tell them how much NPs can charge in private practice. Then I show them psychologytoday profiles of psych NPs and everyone is absolutely shocked. They seem to think NPs have to be hired and whoever does the hiring will make sure the NPs are trained well. But NPs don't have to be hired in 21 states and more medical students need to be shown that these independent private practice NPs are making a lot of money because patients are actually going to them to see them.

The situation is dire and while you are probably right that if we just focus on doing the right thing maybe the political climate will swing back in our favor and physicians will be okay. But to me that feels very defeatist. I feel like instead we need to actually fight back and stop being so passive. Truly unite as a profession and stop this craziness. If we are just going to keep on being passive I'm going to have to become a surgeon instead of a psychiatrist. Since apparently it's every specialty for themselves when it comes to fighting midlevel independence.

If the listed pay rate is part of an insurance practice, it doesn't really matter much, what matters more are the contracts the insurance companies offer and their rates. So their listed fee schedule of an ARNP can be a bit of red herring.

As student who still has all doors wide open I understand your angst in processing the pros/cons of each specialty. In brief I started out thinking rural primary care and do it all, then in med school shifted more towards surgical application, and on the wards, realized I liked psych. Listened to my inner self and ran with psych. At times I have day dream days where I think I should have just done surgery.

Ultimately, the more true to yourself you are the better you stand to be happy - even if it means seeing just how much of an impact ARNPs will really have in Psychiatry and other specialties. But if General Surgery is resonating with you more, go get 'em tiger.

What will make you happy and what do you really want?

 

[Splenda88]

Oh noooo, he's gonna be a surgeon, he's too afraid of competition and insecure in his own ability to stand out as an exceptional provider! We're gonna lose him!

You seem more bothered by what other people can make than what you can make for yourself. Seems like a rather unhealthy mindset. You should focus on finding a career you enjoy that will pay enough for you to get by.

And trust me, there's plenty of room for good psychiatrists and there will be for the remainder of your working lifetime. We provide a qualitative difference to our patients that many appreciate and are willing to pay a differential for. If you think of psychiatry as different people making the same widgets with different credentials, you've already misunderstood the game.

I am not sure if this type of mentality will serve us well, to be honest. I think the poster concerns are legitimate and should not be ridiculed. Things will probably be alright for you and I, but the profession will be unrecognizable 15+ years from now unless WE do something

 

[Mad Jack]

I am not sure if this type of mentality will serve us well, to be honest. I think the poster concerns are legitimate and should not be ridiculed. Things will probably be alright for you and I, but the profession will be unrecognizable 15+ years from now unless WE do something

I mean, I've already geared myself toward an area of psychiatry that midlevels won't touch, so I think I'll be fine either way, at least within my working lifetime. Simple fact is, we as psychiatrists we have more opportunity to work for ourselves than almost any other field, so regardless of how much employed positions change you will always be free to be your own boss.

 

[Splenda88]

I mean, I've already geared myself toward an area of psychiatry that midlevels won't touch, so I think I'll be fine either way, at least within my working lifetime. Simple fact is, we as psychiatrists we have more opportunity to work for ourselves than almost any other field, so regardless of how much employed positions change you will always be free to be your own boss.

Might be the case for psych, but it's not true for IM. I am starting to see NP hospitalist and if this trend continues, the job market will get tighter. My point was that we also have to think about the generation of docs that are coming after us.

 

[deleted480308]

Might be the case for psych, but it's not true for IM. I am starting to see NP hospitalist and if this trend continues, the job market will get tighter. My point was that we also have to think about the generation of docs that are coming after us.

Supervised or not?

 

[Splenda88]

Supervised or not?

Supervised... they are borrowing a page from the ED model.

 

[mememaster9000]

Oh noooo, he's gonna be a surgeon, he's too afraid of competition and insecure in his own ability to stand out as an exceptional provider! We're gonna lose him!

You seem more bothered by what other people can make than what you can make for yourself. Seems like a rather unhealthy mindset. You should focus on finding a career you enjoy that will pay enough for you to get by.

And trust me, there's plenty of room for good psychiatrists and there will be for the remainder of your working lifetime. We provide a qualitative difference to our patients that many appreciate and are willing to pay a differential for. If you think of psychiatry as different people making the same widgets with different credentials, you've already misunderstood the game.

If you were a CEO in a board meeting discussing how a competitor company was able to bribe/blackmail politicians to allow them to avoid following the same regulations that your company follows, and because they are exempt from the same regulations they can flood the market with a product that the general public can't differentiate from your own product. A product which they can receive quicker and cheaper. Then that competitor puts out studies to prove that their product is just as good as your own and also shows the customers rate the experience higher. Would you be happy if the board told you the CEO that you shouldn't worry about the politics behind what is happening? They say "haha you are just afraid of competition!" "If you were actually a smart hard working CEO you would be able to beat the competitor despite their unfair advantages." I'm sure you would enjoy being in that position. /s

And if you really think consumers can figure out which psychiatrist is an exceptional psychiatrist and which one isn't I suggest spending more time on various internet forums. Anti-vaxxers are usually also anti-psych and there are actually more anti-psych than there are anti-vaxxers in the world. Psychiatry is just big pharm trying to control our brains after all. You sheeple need to wake up. /s

I'm sure you have also seen people on SDN talk about how patient ratings are being used as a metric to evaluate doctors and these discussions always devolve into everyone pointing out that patients give better ratings to the doctors who do stuff like give them opioids. So you think a high school kid who wants some Adderall is going to an NP or to you, the exceptional psychiatrist.

Also look how often people say they have an NP as their primary care provider and they say how amazing their NP is. They say oh don't worry about my NP not being a real doctor because my NP always refers me out to specialty physicians so I know I'm getting great care. A huge portion of the population is replacing primary care physicians with NPs and then they start to think that only specialty physicians are real doctors. How soon until psychiatry is replaced as well and then the only "real" doctors in the eyes of the public are the procedural specialties?

 

[Mad Jack]

Might be the case for psych, but it's not true for IM. I am starting to see NP hospitalist and if this trend continues, the job market will get tighter. My point was that we also have to think about the generation of docs that are coming after us.

There's a reason I'm not in IM. Reasons, really. Many.

 

[Mad Jack]

If you were a CEO in a board meeting discussing how a competitor company was able to bribe/blackmail politicians to allow them to avoid following the same regulations that your company follows, and because they are exempt from the same regulations they can flood the market with a product that the general public can't differentiate from your own product. A product which they can receive quicker and cheaper. Then that competitor puts out studies to prove that their product is just as good as your own and also shows the customers rate the experience higher. Would you be happy if the board told you the CEO that you shouldn't worry about the politics behind what is happening? They say "haha you are just afraid of competition!" "If you were actually a smart hard working CEO you would be able to beat the competitor despite their unfair advantages." I'm sure you would enjoy being in that position. /s

And if you really think consumers can figure out which psychiatrist is an exceptional psychiatrist and which one isn't I suggest spending more time on various internet forums. Anti-vaxxers are usually also anti-psych and there are actually more anti-psych than there are anti-vaxxers in the world. Psychiatry is just big pharm trying to control our brains after all. You sheeple need to wake up. /s

I'm sure you have also seen people on SDN talk about how patient ratings are being used as a metric to evaluate doctors and these discussions always devolve into everyone pointing out that patients give better ratings to the doctors who do stuff like give them opioids. So you think a high school kid who wants some Adderall is going to an NP or to you, the exceptional psychiatrist.

Also look how often people say they have an NP as their primary care provider and they say how amazing their NP is. They say oh don't worry about my NP not being a real doctor because my NP always refers me out to specialty physicians so I know I'm getting great care. A huge portion of the population is replacing primary care physicians with NPs and then they start to think that only specialty physicians are real doctors. How soon until psychiatry is replaced as well and then the only "real" doctors in the eyes of the public are the procedural specialties?

Believe what you want, but psych is challenging enough that both midlevels and many doctors fail to meet patient expectations. Be good and you won't have a problem. Don't be an employee and patient surveys don't matter

 

[Splenda88]

There's a reason I'm not in IM. Reasons, really. Many.

Lol... I was between IM/Neurology and I realized after the fact that I have should have chosen neurology, then again I have seen neuro midlevels at my big Ivory tower

 

[mememaster9000]

Oh noooo, he's gonna be a surgeon, he's too afraid of competition and insecure in his own ability to stand out as an exceptional provider! We're gonna lose him!

You seem more bothered by what other people can make than what you can make for yourself. Seems like a rather unhealthy mindset. You should focus on finding a career you enjoy that will pay enough for you to get by.

And trust me, there's plenty of room for good psychiatrists and there will be for the remainder of your working lifetime. We provide a qualitative difference to our patients that many appreciate and are willing to pay a differential for. If you think of psychiatry as different people making the same widgets with different credentials, you've already misunderstood the game.

I know it appears I'm overly concerned with the money so let me explain that. My fellow medical school classmates aren't concerned about independent midlevels because they believe the online salary surveys from employed positions which shows midlevels make less money than MD/DOs. Before I came across psychologytoday profiles I had no way to know what private practice NPs were making. There is no MGMA data on private practice NPs after all. But I became suspicious after reading in the pain medicine forum how CRNAs are making money in private practice doing pain procedures with no anesthesiologists in the clinic at all. These are fully owned and operated by CRNAs. But that is still subjective and unverifiable. Although you can see jobs on gasworks.com and see some CRNA owned jobs on there. No way for me to know how much they charge vs MD/DO. But then I came across these psych profiles that show exactly how much they charge and there are thousands of profiles in all 50 states. Now no one can claim NPs aren't out there trying to take as many patients away as they can. And we can see that they aren't here to fulfill a shortage and help the needy. No, they are out here charging the same as MD/DOs. Seriously go look at other states besides just Alaska like I linked in the op. Because some of you are right that she takes insurance so likely makes less reimbursement but I assure you other NPs on there are doing cash only.

Now psych cash practice isn't the only goldmine out there for NPs to take advantage of. But how am I going to research how much an independent derm NP makes? A men's health clinic testosterone shot NP clinic is making? Who knows what else these greedy NPs got up their sleeves? But I know a lot of you see other doctors as just a bunch of greedy bastards taking advantage of patients in these elective medicine clinics and yet you don't think independent NPs are out there copying them? The difference is they have no training, they get to start at a younger age, they don't have the same debt and they can own hospitals if they want? You like to hate on greedy doctors where is the hate for greedy NPs and now I finally have some real numbers to prove what I'm talking about. Good luck getting an entrepreneurial NP in those other practices they own to tell you what they are making.

I have also seen psychiatrist jobs where the clinic is owned by an NP advertising wanting to hire an MD or an NP. I didn't save the advertisement but when I came across it, it made my blood boil. They see you as their future employees.

People in general only care about things if it effects them economical. So this post had to be about money or else would anyone even read it or reply. Would anyone actually see the real threat NPs pose? Because it seems like no one can show me some real numbers on NPs hurting and killing patients. So I guess we have to talk about the money angle instead until we can prove they are unsafe and causing harm.

 

[Mad Jack]

I know it appears I'm overly concerned with the money so let me explain that. My fellow medical school classmates aren't concerned about independent midlevels because they believe the online salary surveys from employed positions which shows midlevels make less money than MD/DOs. Before I came across psychologytoday profiles I had no way to know what private practice NPs were making. There is no MGMA data on private practice NPs after all. But I became suspicious after reading in the pain medicine forum how CRNAs are making money in private practice doing pain procedures with no anesthesiologists in the clinic at all. These are fully owned and operated by CRNAs. But that is still subjective and unverifiable. Although you can see jobs on gasworks.com and see some CRNA owned jobs on there. No way for me to know how much they charge vs MD/DO. But then I came across these psych profiles that show exactly how much they charge and there are thousands of profiles in all 50 states. Now no one can claim NPs aren't out there trying to take as many patients away as they can. And we can see that they aren't here to fulfill a shortage and help the needy. No, they are out here charging the same as MD/DOs. Seriously go look at other states besides just Alaska like I linked in the op. Because some of you are right that she takes insurance so likely makes less reimbursement but I assure you other NPs on there are doing cash only.

Now psych cash practice isn't the only goldmine out there for NPs to take advantage of. But how am I going to research how much an independent derm NP makes? A men's health clinic testosterone shot NP clinic is making? Who knows what else these greedy NPs got up their sleeves? But I know a lot of you see other doctors as just a bunch of greedy bastards taking advantage of patients in these elective medicine clinics and yet you don't think independent NPs are out there copying them? The difference is they have no training, they get to start at a younger age, they don't have the same debt and they can own hospitals if they want? You like to hate on greedy doctors where is the hate for greedy NPs and now I finally have some real numbers to prove what I'm talking about. Good luck getting an entrepreneurial NP in those other practices they own to tell you what they are making.

If you want to be a grifter, be a grifter. NP gives you a low bar for entry.

I want to be the best damn psychiatrist I can be. I could just as easily grift. Swear I'm "different" because I'm a DO, offer bull**** hormone therapy for depression, tell them I'm more patient centered and that my custom vitamin regimen will restore balance to their receptors in a natural way. But I'm not a damn grifter. I respect myself and the practice of medicine, and this isn't about money. It's about providing the best care possible with the best skillset available.

 

[mememaster9000]

If you want to be a grifter, be a grifter. NP gives you a low bar for entry.

I want to be the best damn psychiatrist I can be. I could just as easily grift. Swear I'm "different" because I'm a DO, offer bull**** hormone therapy for depression, tell them I'm more patient centered and that my custom vitamin regimen will restore balance to their receptors in a natural way. But I'm not a damn grifter. I respect myself and the practice of medicine, and this isn't about money. It's about providing the best care possible with the best skillset available.

I don't understand how you think I'm a grifter for being angry that NPs bribed or blackmailed there way into having the same legal status to practice medicine?

It's good you hold yourself to such a high standard. I'm in medical school I also want to hold myself to a high standard like you. But the NPs being able to be grifters destroys the publics perception of this profession and it hurts all of us. Current and futures physicians.

 

[mememaster9000]

If you want to be a grifter, be a grifter. NP gives you a low bar for entry.

I want to be the best damn psychiatrist I can be. I could just as easily grift. Swear I'm "different" because I'm a DO, offer bull**** hormone therapy for depression, tell them I'm more patient centered and that my custom vitamin regimen will restore balance to their receptors in a natural way. But I'm not a damn grifter. I respect myself and the practice of medicine, and this isn't about money. It's about providing the best care possible with the best skillset available.

But it definitely is about money or else why would politicians give them the same legal status in 21 states? You think they are doing that without money being the motivation?

 

[Splenda88]

If you want to be a grifter, be a grifter. NP gives you a low bar for entry.

I want to be the best damn psychiatrist I can be. I could just as easily grift. Swear I'm "different" because I'm a DO, offer bull**** hormone therapy for depression, tell them I'm more patient centered and that my custom vitamin regimen will restore balance to their receptors in a natural way. But I'm not a damn grifter. I respect myself and the practice of medicine, and this isn't about money. It's about providing the best care possible with the best skillset available.

You need to look at things 15+ years down the road... We can not throw our hands in the air and say " Well, I'll be a good damn psychiatrist."

 

[mememaster9000]

If you want to be a grifter, be a grifter. NP gives you a low bar for entry.

I want to be the best damn psychiatrist I can be. I could just as easily grift. Swear I'm "different" because I'm a DO, offer bull**** hormone therapy for depression, tell them I'm more patient centered and that my custom vitamin regimen will restore balance to their receptors in a natural way. But I'm not a damn grifter. I respect myself and the practice of medicine, and this isn't about money. It's about providing the best care possible with the best skillset available.

If you respect medicine as a profession so much why are you cool with NPs destroying the integrity of medicine?

 

[Splenda88]

If you respect medicine as a profession so much why are you cool with NPs destroying the integrity of medicine?

I have followed him and he was not cool with it when he was a premed and med student. I guess he is so close to being an attending, so he probably feels like that NPs have won the battle.

 

[Mad Jack]

I have followed him and he was not cool with it when he was a premed and med student. I guess he is so close to being an attending, so he probably feels like that NPs have won the battle.

I am close enough that I realize it is impossible for them to win

If you respect medicine as a profession so much why are you cool with NPs destroying the integrity of medicine?

They aren't practicing medicine, they sacrifice their personal integrity not ours. In time, we will win, as was the case with Flexner when charlatans reigned a hundred years ago. You are far too shortsighted

 

[mememaster9000]

I am close enough that I realize it is impossible for them to win

They aren't practicing medicine, they sacrifice their personal integrity not ours. In time, we will win, as was the case with Flexner when charlatans reigned a hundred years ago. You are far too shortsighted

Do you really think when a patient gets hurt they are going to see it as an NP hurt them and not see it as medicine has hurt them? Do you not think the patients will ask questions such as, "but I thought NPs were safe? why else would physicians let them practice on equal footing if they weren't safe?"

You see physicians will still be responsible even when they aren't actually responsible. The patients will blame physicians for letting NPs practice. They won't see it as politicians caused this to happen and physicians' hands were tied. They will see it as we have failed to protect them and fight for them.

 

[Mad Jack]

Do you really think when a patient gets hurt they are going to see it as an NP hurt them and not see it as medicine has hurt them? Do you not think the patients will ask questions such as, "but I thought NPs were safe? why else would physicians let them practice on equal footing if they weren't safe?"

You see physicians will still be responsible even when they aren't actually responsible. The patients will blame physicians for letting NPs practice. They won't see it as politicians caused this to happen and physicians' hands were tied. They will see it as we have failed to protect them and fight for them.

And we will have mountains of evidence to the contrary. It will be fine.

 

[downwithDTB]

Supervised... they are borrowing a page from the ED model.

There are plenty of unsupervised (or minimally supervised so that the physician couldn't actually know what's really going on) out there as well and the trend is moving that way.

The current private practice cash model is largely dependant on out of network benefits. If universal medi-something kicks in and reimbursement craps out, it's going to get real hard to convince most people to pay $300 to see an MD when the NP is free, and definitely not on a recurring basis. Certainly not if the NP gives them some Xanax first appointment and it WORKS until it doesn't. There just aren't enough rich people who will be choosers.

And if you think that malpractice is going to even things out, remember, they will be held to a nursing standard and judged by peers. See Shelton vs. urgent care.

Wrong expert testifies in a professional negligence case

In professional negligence cases against nurses and other healthcare providers, the expert witness must be a healthcare practitioner familiar with the standard…

www.nurse.com

 

[mememaster9000]

And we will have mountains of evidence to the contrary. It will be fine.

We wouldn't even have independent midlevels if the federal government would increase residency positions enough to prevent a physician shortage. This is another example of how it was just about the money to the government.